The Stigmatization of Borderline Personality Disorder
Borderline personality disorder is often considered among the most emotionally painful (for sufferers and those affected by them) personality disorders. BPD is often diagnosed on the basis of quite a few symptoms and behaviors. BPD is a serious mental disorder with a characteristic pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image.
(Lancet 2004) It is known to affect about 1-2% of the general population.
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Borderline personality disorder causes severe impairment in the sufferer’s life. They struggle daily with controlling their emotions, thoughts, and actions. They often describe having wild mood swings, making it difficult to describe their exact feelings at any given moment. Their opinions and outlook on life situations are prone to change rapidly and uncontrollably, making it hard for them to maintain a positive or consistent outlook on almost anything, especially when it comes to social relationships. They tend to exhibit a behavior which is known as “splitting”, in which they will view every situation in black and white, rather than with gray areas, like a neurotypical individual. This is especially evident in their interpersonal interactions. They can go from idolizing or being absolutely infatuated with someone, to hating them in a split second. While this is out of their control, it is especially painful for those close to them. They also tend to have difficulty managing these thoughts, which tends to make them feel out of control or to self label themselves as “crazy” or “insane”. This can make it hard for sufferers to feel like they even know themselves, and have a hard time establishing their own identity, which is rapidly shifting and unstable.
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Those afflicted with this disorder tend to seek professional help, especially in times of great crisis. According to Robert S. Biskin’s academic article The Lifetime Course of Borderline Personality Disorder, Sufferers of BPD are often seen only when in times of crisis, if they are not already part of a long time treatment program. This leads many to have the impression that those with BPD are constantly in crisis and are never recovering, which in turn causes mental health professionals to stigmatize these individuals and give them little to no real treatment. However, research shows the opposite of this.
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According to Robert S. Biskin’s academic article “The Lifetime Course of Borderline Personality Disorder,” sufferers of BPD . . . .
In the McLean Study of Adult Development, a group of 290 patients originally hospitalized at McLean Hospital with a diagnosis of BPD, were assessed 6 months after the start of the study, and then annually for 10 years. By the end of the study, 85% of patients described a 12 month or longer period of symptom remission and improvement. This proves that with proper care and treatment, sufferers of borderline personality disorder do have the potential to make significant progress and live better lives.
In a similar study by the American Journal of Psychiatry, a group of 38 patients diagnosed with borderline personality disorder were placed in either partially hospitalized care, or standard psychiatric, appointment based care. Both groups were measured on their frequency of self harm or suicide attempts, number of inpatient admissions, and their own measures of depression, anxiety, and interpersonal function. The partially hospitalized group of patients showed substantially decreased negative symptoms when compared to the group met with standard psychiatric care. This shows that specialized care for these individuals is key to helping them improve their condition significantly and properly.
According to Lindsay Sheehan’s psychiatric article The Stigma of Personality Disorders, stigma can be described as a range of a lack of eye contact, to complete ostracization of an individual belonging to a stigmatized group. Due to public attitudes towards mental illness, the mentally ill are often seen as to blame for their behaviors, as if it is their conscious choice to act out. Not only is BPD among the most stigmatized of all personality disorders, but it is also the most researched in terms of Stigma.(Sheehan 2016) When asking nurses in Israeli psychiatric hospitals about their views of different mental health patients, they showed the most negative attitudes towards those with Borderline Personality Disorder. Another study showed that psychiatrists tend to exhibit the least empathy towards those with BPD.
This is a very complicated issue not only because of the poor treatment, but for the reason that this knowledge completely discourages sufferers from seeking help. Why would you seek help, when you know the person helping isn’t going to do their job? This is the kind of helpless mindset that those with BPD often have not only towards their lives in general, but also their healthcare providers. There needs to be established trust and transparency between patients and mental health specialists, as this is the only way effective treatment can occur.
In Amanda Vandyk’s original article titled Why go to the emergency department? Perspectives from persons with borderline personality disorder, she states that most healthcare providers describe that patients with BPD are “difficult” and “a pain in the ass”. This kind of attitude shows that a portion of clinicians clearly dread dealing with these patients. They have also been found to describe patients as “attention-seeking” and “manipulative”. Those with BPD suffer from intense feelings of loneliness, despair, and fear of abandonment. This directly triggers an emotional response due to these fears.
The most important thing to remember about individuals with BPD is that they never choose to act the way that they do. The symptoms of BPD are extremely intense and uncontrollable. Sufferers struggle to survive in their own skin with these symptoms, which is why they seek licensed professionals to help them. If they could control these feelings, thoughts, and behaviors, they wouldn’t be in a psychiatrist’s office multiple times a week looking for assistance. Understanding and acknowledging the struggles of those with borderline personality disorder is imperative to treating them. Healthcare professionals need to take the time to evaluate these people respectfully and develop better strategies to treat and handle them. With a personality disorder mainly characterized with a fear of feeling hopeless and alone, turning a sufferer away rather than helping them pushes them down a hole they will have a very hard time climbing out of on their own.
Despite how cruel the stigma of this mental health affliction is, it doesn’t exist for no reason. People with BPD are admittedly uncontrollably troublesome, incessant, and hard to control. The frequency of their suicide attempts is often seen as attention seeking, and people hospitalized from their BPD are often discharged faster than any other group of patients in a hospital. (Sheehan 2016) This is because of their emotionally extreme and outrageous behaviors.
Those with BPD have a lot on their plate, as we already know. They can’t control their emotional responses nearly as well as an average person, and their moods never settle to a stable position for very long. They have to hide their diagnosis out of fear of people finding out and labelling them crazy, or distancing themselves from them. With a constantly cluttered mind and dysregulated emotions, they are like a time bomb waiting to explode any second into impulsive behaviors galore.
We see insanely high rates of hospitalization from this group of mental health patients. They make up 9% of all psychiatric emergency room visits in the US. (Hong 2016) Despite being stigmatized, these individuals still seek the care of emergency providers. It may seem counterproductive to do this, but the answer is depressing, but unfortunately true. These people have absolutely nowhere else to go when they NEED help. The critical emotional state that BPD sufferers are internally capable of reaching is very dangerous. While in this state, they can and will make very impulsive decisions. This can include sex, rampant drug use, or even attempted suicide. They can’t be trusted to be left alone. For this very reason, they need to be observed, protected, and controlled for the time that they are hospitalized. This makes the stigma they receive almost unavoidable, which makes a double edged sword: Go to the ER to protect your own life while being treated like a nuisance, or stay home and risk hurting yourself or even others.
One of the reasons that ER staff become so irritated, annoyed, and tired of borderline personality disorder patients is due to the frequency of visits, comorbidity of symptoms, and their attitudes. According to Victor Hong MD’s journal Borderline Personality Disorder in the Emergency Department: Good Psychiatric Management, “High rates of comorbidity (mood disorders, anxiety disorders, substance use disorders, and eating disor- ders) among BPD patients further complicate matters. BPD patients are often advised to visit the ED when in crisis and when safety is in question, but experiences in the ED can dam- age the patient and undermine treatment progress.” BPD related visits often end up becoming seriously complicated due to either misdiagnosis, or other conditions presenting themselves. BPD sufferers often present symptoms of various other mental health conditions. This includes Obsessive Compulsive Disorder, Chronic Depression, and Attention Deficit Hyperactivity Disorder. This can make treatment and diagnosis very tricky and complicated for doctors.
BPD patients are also very frequently showing up to the ER. BPD remains one of the most common hospitalized mental health conditions. Those with BPD have a very hard time functioning on their own, and need to rely on emergency services when they need it. Symptoms of BPD fluctuate in severity from patient to patient, but anyone who is previously untreated is going to have much more intense and prevalent symptoms than someone who has been in therapy before.
In author Cameron Hancock’s article The Stigma Associated with Borderline Personality Disorder, he claims “Individuals experiencing BPD are also frequently labeled as “treatment resistant” and dropped as patients. But when this happens, it reinforces the common misconception that reaching out for help is hopeless. It can also intensify symptoms that caused an individual to seek help in the first place…” Knowing this, it makes it no surprise that sufferers keep coming back for more. BPD patients go to the emergency room when it is absolutely necessary for their survival. This means that they are in an emotionally vulnerable state in every single way possible. They already have a hard time communicating when they aren’t even necessarily in crisis, so this is magnified by a considerable amount when they are barely hanging on to their lives. This can make it very difficult for doctors to help them, as they might try and refuse help from the doctor. At some point, the effort might seem meaningless or futile to a doctor and he/she may just give up on the patient. “The emotional dysregulation and hypochondriasis so com- mon in BPD patients can lead to hostility and dysregulation in their mental health providers. The often inadequate in- terview spaces, lack of appropriate disposition options, and limited time with which to assess patients in the psychiatric ED only heighten the tension.” (Hong 2016) Doctors can also end up even being hostile towards patients. Not only is the BPD patient feeling potentially hostile, but this can spark that behavior in the doctor out of pure frustration. This dynamic can be very dangerous physically, mentally, and emotionally. From this situation, the displayed behaviors from the patient will only escalate further and further. In their most critical time, they are expecting to be given tender and gentle care to help get them back to health. When a doctor responds in such a hostile manner, it can seriously damage the patient’s ability and willingness to continue with the given care.
Even if this is wrong from a professional or moral perspective, it does make sense. Possibly the worst part of these situations is that it just reinforces the BPD sufferer’s distorted worldview of perceived abandonment, making them even harder to treat in the future. This cycle continues to repeat, doctor after doctor, until the person in question has absolutely no idea of where to go from there. With clear causes identified as to why BPD patients are stigmatized, we may be able to begin to help both doctors and patients find a healthy middle ground when it comes to treatment.
The stigmatization of individuals diagnosed with borderline personality disorder does not end in the emergency room or the doctor’s office. The stigma really becomes a serious issue when it lends itself towards criminal activity, and the unjust perception that criminals are often BPD sufferers.
A lot of criminal activity is either blamed on psychopathic personality traits, or entirely attributed to personality disorders in general. This leads to the general perception that those with borderline personality disorder, or other personality disorders, are inherently capable of criminal activity, on any scale. While it is absolutely possible that someone with a personality disorder can commit any kind of crime, be it violent or just petty, it is not solely those individuals that perpetrate criminal activities.
Psychologist Melvin Konner, M.D., Ph.D. states “In essence, day-by-day evil is done by people with certain severe personality disorders…” he also claims “The thing about them though, is that they often love intensely and inspire the love of others. That’s what makes them powerful and what makes the people around them vulnerable. Their love is intense, controlling, unreliable, and toxic.” when referring to BPD patients in specific. While it is possible that there are criminals committing crimes on a daily basis that fall into the category of a borderline personality diagnosis, it cannot be concluded that all day-by-day crime is committed by those with personality disorders.
First, we need to examine the personality traits of those with borderline personality disorder that may lead them to commit crime. Individuals with BPD have a lot on their plate when it comes to impulse control and emotional regulation. These people typically have a very hard time controlling their impulses, and this symptomatology can vary in severity from person to person, similar to how it would in a neurotypical group of individuals. The difference between impulsivity in those with borderline personality disorder and a neurotypical individual is the response to those impulses. Those with BPD may have a hard time rationalizing avoiding a dangerous activity, or one that puts others in potential danger. Being that this emotional impulsivity exists stronger in BPD patients, it can paint the picture that they are more prone to committing crimes. However, this is not necessarily the case.
In the article Personality Disorders and Violence: What is the link? by Richard Howard, he claims “Moreover, antisocial/borderline PD comorbidity has been found to be strongly associated with degree of severe violence perpetrated by personality disordered offenders.” There are so many factors that need to be taken into account when generalizing a population of mental health patients, especially comorbidity. Comorbidity is the existence of multiple factors that play into the result of a given negative situation. While borderline personality disorder has never been found to be conclusively violent or inherently criminally motivating, antisocial personality disorder has been found to be a driving force in criminal activity. People with antisocial personality disorder tend to act carelessly and completely disregard the safety, feelings, and well-being of everyone around them. This is not characteristic of borderline personality disorder. When two conditions exist within the same person, it becomes nearly impossible to blame one aspect of their personality for their actions, which leads to a generalized viewpoint of all aspects of their personality playing into their violent/dangerous behavior.
In psychologist Sudhinta Sinha’s academic article Personality correlates of criminals: A comparative study of normal controls and criminals she says “If we scrutinize the life histories of people who commit and are convicted of real, or victimizing, crimes, especially the histories of recidivist criminals, we find that the criminal’s personality has become organized around the principle of attacking, going against, and taking from people as his/her way of relating to them. Early in life, he/she learned to take what he/she wanted. Once the personality is so organized, he/she repeatedly commits crime, and he/she does so compulsively.” This is the typical case when it comes to criminals: their behavior stems from a long history of acting out, or being horribly abused. When looking at borderline personality disorder, we don’t find this to be the cause. Individuals with borderline personality disorder usually begin to show symptoms of their condition after childhood neglect, sexual trauma, and physical abuse. The structure of someone with borderline personality disorder by itself is different than someone who is a violent, psychopathic criminal. Those with BPD tend to regress, rather than progress into someone who is violent. Their behaviors often serve as coping mechanisms and a way to defend themselves, and this doesn’t make them act out violently. Borderline personality disorder is not often categorized as violent, or maliciously cruel, while psychopathic disorders such as antisocial personality disorder are.
Konner claims that those with borderline personality disorder use their intense emotions of love and attachment to their advantage, and this helps them make those around them vulnerable and emotionally compromised. While this is a true tendency of those with borderline personality disorder, it does not suggest criminal activity. These behaviors are often primarily exemplified in interpersonal relationships, rather than unprovoked crime or violence. The damage that these behaviors cause is limited to emotional damage in another person, not physical violence. Generalizing BPD sufferers in with all other personality disorders and their related crimes therefore does not carry any real weight.