Why Borderline Personality Disorder is Misdiagnosed

By Alan E. Fruzzetti, Ph.D. | Oct. 03, 2017

 

Living with Borderline Personality Disorder (BPD) is difficult for many reasons, including unstable relationships, emotional reactivity and dysregulation, impulsivity, and other challenging features. But what makes the condition even harder is that many people who live with Borderline Personality Disorder don’t even know they have it.

BPD is one of the most commonly misdiagnosed mental health conditions. It’s so misdiagnosed, in fact, that there isn’t even an accurate prevalence rate for the condition. What we do have is an estimate of 2–6% of the population, which actually makes BPD very prevalent. So how is it possible that a prevalent condition is so misdiagnosed? Here are just a few reasons why that could be.

Stigma in Society and Among Professionals

BPD is one of the most heavily stigmatized mental health conditions a person can experience. This rampant stigma has both tangible and emotional consequences that can worsen existing difficulties with BPD. In the form of judgments, blame, negative assumptions and discrimination, stigma can lead a person experiencing BPD to feel ashamed and hide their suffering. This leads to further negative emotion (shame, loneliness, fear) and attempts to suppress distress. Suppression of distress and self-invalidation typically results in further emotion dysregulation, dysregulated thinking and out-of-control behavior.

Even if individuals are determined enough to push through the stigma and seek treatment, they may encounter even more stigma. Some mental health professionals are reluctant, or even refuse, to diagnose and/or treat BPD even when a person clearly meets diagnostic criteria.

The Myth That Teens Can’t Have BPD

This problem is even more pronounced among adolescents: Many clinicians fear that even correctly diagnosing a teenager with BPD will only worsen their problems because of stigma. In addition, many professionals incorrectly believe that it is not possible to diagnose BPD in adolescents. This results in underdiagnoses and inaccurate prevalence rates. Worst of all: It prohibits teens from receiving the specialty care they need when early detection and early intervention are essential to recovery.

BPD Looks Like So Many Other Mental Health Conditions

People with BPD typically also meet the criteria for multiple other diagnoses, including depression, anxiety, post-traumatic stress disorder, substance use disorders, eating disorders, bipolar disorder, and so on. These disorders, of course, are not independent of BPD, but are connected and related through shared psychological, social and biological pathways. However, when these other diagnoses are the focus of treatment, they can dominate professionals’ attention, preventing any significant focus on the whole pattern of difficulties, resulting in missed diagnosis of BPD.

In particular, there is evidence that BPD is commonly misdiagnosed as Bipolar Disorder, Type 2. One study showed that 40% of people who met criteria for BPD but not for bipolar disorder were nevertheless misdiagnosed with Bipolar Type 2. This is most likely due to some similarities between symptoms: impulsive behavior, intense emotions and suicidal thinking. However, they are very different diagnoses with different treatments methods, so it’s crucial for mental health professionals to understand and know the difference.

The Myth that BPD Isn’t Treatable

Some of the problems with diagnosing result from the fact that there was no evidence of effective treatment for BPD until the 1990s. The first published evidence for the effectiveness of Dialectical Behavior Therapy was by Marsha Linehan in 1991. Before then, many clinicians blamed people with BPD for not getting better, rather than acknowledging that professionals had not yet figured out how to treat people with BPD successfully, or trying to find more effective pathways for treatment. Today, unfortunately, many professionals continue to think that BPD is not treatable despite growing evidence that it is. This leads some professionals to avoid giving the diagnosis even when someone meets the criteria.

But Only Women Can Have BPD, Right?

Gender is another factor in misdiagnosis. The epidemiological rates of BPD in males and females are roughly equal. However, females are over-diagnosed and males are underdiagnosed significantly. This happens in part because women are overrepresented in most studies and treatment. Stereotypes about masculinity and femininity are also likely at play. It’s no surprise that females, who have long been stereotyped for being “emotional” or “hysterical,” are the ones who are over-diagnosed.

Of course, there are many other factors that influence the accuracy (or inaccuracy) of a BPD diagnosis. However, the more individuals with BPD and their families become aware of these problems, the more they can advocate for accuracy. A lack of understanding about BPD already prevents people from seeking treatment. So, for those who do seek help, we should make sure they are getting the proper treatment. And that starts with getting the correct diagnosis.

 

Alan E. Fruzzetti, PhD, is the program director of the 3East Boys Intensive Program and the director of Family Services for 3East Continuum. He has adapted and implemented dialectical behavior therapy for underserved populations, and developed many successful DBT programs for people with borderline personality disorder and other problems with emotion regulation. Dr. Fruzzetti is on the Board of Directors of the National Education Alliance for Borderline Personality Disorder, the International Society for DBT, and the Linehan Institute. 

Comments
KRBM
There is no explanation of what BPD is or what effective treatments are. This leaves a big gap in the article.
10/31/2017 5:53:08 PM

Alice Henderson
I have a daughter with BPD and she had all the symptoms in her teens, and she acted out a lot, and now she is 36, and married to a guy who is an alcoholic, former meth addict, Bipolar, and severe Malignant Narcissism, he has been abusing two of our grandsons since they were little, they are 18 and 17 now, the 18 year old has signs of PTSD because of the abuse, he may have BPD too, the stepfather bullied, terrorized these two boys nearly their whole life, continues to hurt them mentally, he beat and tortured them and now they are damaged. They will need help, and his son our youngest witnessed the abuse of his brothers, so he is hurting too, he's 14.
10/30/2017 11:28:50 AM

Donna
Thank you for this illuminating, compassionate post. I fear I am one of the potential patients of BPD 'lost in the shuffle' of accompanying mental illness (major depression, eating disorder (AN) and anxiety)...and my psychiatrist (ED)...while admitting that I indeed 'showed all of the signs' of a clear BPD diagnosis, told me he did not want to 'hang' that label onto me. I was very frustrated, because I truly believe that knowledge is power, and I could have then at least been able to learn about DBT and other skills to overcome it...and I would have had a deep sense of validation. Is it possible in France to find a BPD psychiatrist or one who could make such a diagnosis? My former psychiatrist only wanted to focus on the ED...but there is so much more going on here. Thank you for shining a light on this shadowed subject.
10/29/2017 8:16:49 PM

Rick Stanford
I lived with a BPD wife on and off for 16 years and finally had to live separately since she was making life miserable for us. I tried 2 psychiatrists to get her help but she refused both of them, even dashing out of the office of the second one while filling out the usual questionnaire. Some BPD's , like other mental health sufferers, suffer also from anosognosia: a condition that tells them there is nothing wrong with them, a form of denial. My wife is like that. She accuses me of being the "abusive one" . Even religious organizations refuse to take this problem head on and think that spiritual remedies alone will help these unfortunate souls get better. Some religious organizations refuse even to acknowledge there are such conditions, merely thinking that "original sin" is causing their condition. We need a national recognition of ALL personality disorders so that the curing of them and/or the improvement of their lives takes place in a timely manner. We need a national policy or protocol to recognize anyone who seems to be having difficulties in life to get treatment, without the stigma attached.
If we had had such a protocol, perhaps many marriages and families would be saved from such difficulties and divorces, separations, suicides, imprisonments , drug abuses, etc would not occur or be drastically reduced,.
10/29/2017 1:00:49 PM

Tom Carter,M.D.
Very "trendy", superficial, poorly-informed article.
I suggest the author start by reading Otto Kernberg, M.D.'s book, Borderline Conditions and Pathological Narcissism and then get a few years expert supervision from a Psychoanalyst knowledgeable in Object Relations Psychoanalytic Thepry and practice [plus an analgamated understanding of the other emotional-developmental theorists over the past several decades.
10/28/2017 1:42:14 PM

Daniel Rodriguez
If only they were willing to accept counsel then maybe things would get better. https://www.gofundme.com/newlifejdr
10/27/2017 8:47:05 PM

Tom Haddon
The description and symptoms are found in the BPD link in the first sentence.
10/27/2017 1:38:14 PM

Anon
Useless fluff article. Stop wasting people's time.
10/26/2017 5:31:26 PM

Heather
I would like to know if there are any BPD support groups in the Myrtle Beach, SC area. Thanks!
10/26/2017 4:03:12 PM

MIke
Some commenters here sadly reflect prevalent thinking that an informed author is trying to dispel and aptly justifies more such efforts at education. BPD is not a mental illness in that the treatment does not try to cure anything in the way that you would treat other illnesses. The therapy focuses on skills training so that people with the disorder can experience a life worth living. And it is not true that folks with BPD do not have differences in their brains from people who don't have it. MRI studies have shown that they actually do. Research also shows that people who have it often prefer to have the diagnosis than to be left twisting in the wind as it is the beginning of understanding. It clearly is not simply a label to them and lets them know that they are not broken or evil (other labels sadly that are often applied, often by people with BPD to themselves). Yes, they have some behaviors that often do not serve them well, but human behaviors still. The diagnosis is a critical milestone on the road to an improved life--people who've experienced BPD and DBT know this. The rest of world needs to be brought up to speed, and the mental health community of practitioners needs to adhere to ethical standards and do no harm.
10/26/2017 10:46:04 AM

Kim
This article does not explain what BPD is and the steps to diagnose it, only that it is misdiagnosed. Please explain how to diagnose this mental health issue.
10/26/2017 9:41:30 AM

Wilma Lelek
As a parent who often times "knows better what's going on" than the professionals who see patient for brief time and load on so many medications.Please send more about the form of therapy.
10/26/2017 9:19:04 AM

Jennifer Walton
I am interested in learning more about trainings for treatment of BPD in Buffalo, NY area
10/26/2017 8:04:18 AM

judie russell
my son had issues that considered bpd but I couldn't get him help, he was 302, sent to crisis and released.the system failed him so many times.suicidal thoughts- took to crisis at hospital-sent him home knowing his older brother suicide when he was 8 years old,now 16 and acting out.genious iq and in a special class but dropped out out.alcohol and pot use.drank a pint of vodka just because,very conflictual relationship with father, at 17years, he shot and killed his father, the system again failed him and he was a juvenile tried as an adult and given 15-30 years at a state prison.this is what relly happens to our young men that need help, not prison!
10/26/2017 7:58:10 AM

Lisa
All of this on misdiagnosing and similarities to other illnesses... Yet, I still do not have a clear understanding of BPD...I have heard a psychologist tell me my son has this disorder, then a month later in a psych ER and then 15 days of in patient psych care, that BPD was not a correct diagnosis...then learned my son has schitzophrenia. Once forced to take medicine In order to be discharged, he began attending an IOP under the care of 2 psychiatrists, a psychologist and several therapists. He was discharged early because he was not benefitting from treatment even though medical necessity was there. He left there with a diagnosis of schizoid affective disorder. (They hadn't seen enough evidence to concure with "schitzophrenia")
He has been hospitalized twice since that discharge...different hospitals.... To this day he believes nothing is wrong, stops taking medication after discharge....anasignosia ( I know) his 4th hospitalization was just in late August....he was hiking alone in the Rockies, decided to try Bouldering..fell 50 feet...and spent days in ICU... 2 fractures in neck, 1 in spine, 1 broken rib, many lacerations, stitches....knee injury. He is still in the neck brace 24/7.
10/26/2017 5:57:38 AM

Patricia Orlando
Interesting
10/25/2017 11:09:26 PM

Barbara
I believe my husband to have a mental illness. He meets the criteria for this and Bipolar. His impulsive behavioral have caused our family so much agony and heartbreak. He is following this person with cult like tendency have added to his agony that he is already in denial with. We need help Bad!!
10/25/2017 10:22:23 PM

Keith Brown
Great article, although more should be said about those who have recovered from BPD. I have! A large percentage of BPD sufferers DO get better. And BPD symptoms should be listed in this article, as well.
10/25/2017 9:52:28 PM

Antonio
After reading this article it was very interesting to read. I was very surprised to see so much stigma that comes from Professional.
10/25/2017 7:58:36 PM

Roopa
Thank you so much for saying all the things I have been discussing with friends and co-workers for SO long. I find that many people with BPD are diagnosed with bipolar disorder. It is so wrong with such different treatment. I have been living successfully with BPD for many years now. A combination of medication and DBT saved my life. I am now a mental health advocate, working for NAMI San Diego. I am trying to help others so they do not have to wait until they are 32 to be diagnosed correctly. There are many of us living full lives even with this illness. I continue to be the voice of hope for so many. I am also Indian (NOT Native-American). In our culture, we do not talk about mental illness. I continue to be the face of it for the Indian people. I got better, which means... so can YOU.
10/25/2017 7:37:32 PM

Lydia McKee
My son has been recently diagnosed with bpd after 25 years of misdiagnosis of severe depression and bp and self treating. He had started to use heroin in his pain and ended up in prison. He is on lithium and prozac in prison and appears to be helping in that environment. He and I are afraid of the future when he is out. Looking for a great mental healthcare professional in the Fond du Lac Wisconsin area.
10/21/2017 11:01:59 AM

William Keevers
What distinguishes a psychobble term from accepted jargon in a theory that will likely be discarded in 25 years, forgotten in 50 and unheard of in a century? The presumption of prefacing "regulation" with the unnecessary "dys" makes one disinclined even to question what such a word means. Respect ordinary speech.
10/4/2017 11:56:30 PM

kdn
Giving labels to different “mental illnesses” should stop (not just for BPD, but for all “mental illnesses”). This is because despite decades of research, scientists have not been able to find any structural or other brain differences between patients with mental conditions and healthy individuals (this is why there are no objective tests to detect them). Labels increase stigma and also disempower people.
10/4/2017 6:31:58 PM

Larry Schumacher
This article did not tell me all the symptoms?
10/4/2017 5:47:05 PM

Patricia Alvarez
My son is currently hospitalized for the third time. I've given doctors information that strongly leads me to believe he has BPD, he get diagnosed with other illnesses--depression, anxiety, psychosis, and now possibly schizophrenia. Mental health professionals don't seem to give BPD enough attention; it is so frustrating!
10/4/2017 3:01:03 PM

Erin Cimino
Thank you. Thank you for verbalizing this to a large audience. I have heard so many shaming and hurtful comments within the counseling profession directed toward people with BPD. I myself am working toward getting my master’s degree in Mental Health Counseling and hear such misguided opinions about this diagnosis. No one I’ve worked with, however, realizes that I am currently diagnosed with this disorder and going through treatment. Their comments are so hurtful and make me feel like such a terrible person for something I did not ask for any can’t simply control. So thank you. Thank you for speaking up when I haven’t yet found my voice to do the same.
10/3/2017 7:31:42 PM

JoLynn Simon
Very interesting would like to read more
10/3/2017 11:49:52 AM

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