What’s in a name? Borderline personality disorder and stigma

Borderline personality disorder (BPD) is a disorder of self-function and interpersonal functioning. Its symptoms, which can be confronting, include frantic attempts to avoid abandonment; intense and unstable interpersonal relationships; impulsive behaviour; self-harm; and intense, volatile moods. [1]

It has been estimated that 1% of the population suffers from the most severe form of this condition, but up to 15% of the population have been noted to have a variation of BPD. 72% of these patients are women. People diagnosed with BPD also present a high comorbidity with other mental health issues, such as mood and anxiety disorders. [2] BPD remains poorly understood, people who suffer from this condition are likely to be perceived as chaotic, manipulative and reckless. This stigmatisation occurs not only among the general public but sadly by the very group whose role is to treat these patients: mental health professionals. A 2013 review identified that a majority of healthcare professionals who have participated in previous studies of stigmatisation of BPD have negative feelings towards patients with BPD. Healthcare professionals self-report feeling manipulated, anxious, uncomfortable and apathetic towards patients with BPD, and report perceiving such patients as “dangerous,” “unrelenting”, lacking in coping skills, and “engaging in crisis behaviours.” [3] Additionally, health care providers’ attitudes towards BPD tended to be more negative than those towards mental health conditions more broadly, including other stigmatised conditions, such as schizophrenia or bipolar disorder. [4]

Such stigmatisation can and does adversely impact the therapeutic relationship. Adverse outcomes resulting from stigmatisation can include: emotional distancing from patients; rationalisation of failures in treatment and premature termination of treatment.[4] This diminishes the effectiveness of treatment in the target population, resulting in poorer patient outcomes and contributing to the public health burden.

Why is the name a health issue?

Up to 80% of those diagnosed with this condition have experienced childhood trauma.[5] Indeed, a 2009 systematic review, which applied Hill’s criteria in demonstrating causality, suggested that there is a causal relationship between childhood trauma and the onset of BPD.[6] The aetiology of this condition is almost certainly multifactorial, and remains speculative, but some theories include the ‘cortisol’ hypothesis - children who experience trauma produce high levels of the stress hormone cortisol, which in turn impacts emotional control and regulation.[7]

The very name ‘borderline personality disorder,’ which some mental health professionals increasingly feel is an inappropriate name for this condition [1], obscures this complex aetiology. This name dates back to the 1930s, when this condition was so named because it was perceived to be on the ‘border’ of neurosis and psychosis.[7] It is therefore something of an anachronism, rooted in an unsophisticated understanding both of mental illness and of this specific condition.

Moreover, classifying it as a ‘personality disorder’ suggests that the condition is an intrinsic flaw of the individual, rather than an aetiologically complex response to trauma. This is not a matter of mere semantics: language shapes how we perceive the world. In the case of BPD in particular, one intervention that is effective at reducing stigma - and can thus potentially mitigate some of the adverse treatment outcomes, as noted above, which result from this - is targeted education of healthcare providers.[4] Changing the name can potentially assist in this, by reframing the condition.

The Polygeia Women’s Mental Health Team is currently conducting a systematic review of the evidence to support a name change from BPD to Complex Trauma Disorder. Preliminary studies suggest that the latter name is widely accepted by patients with this condition as it reduces stigma, and because the inclusion of ‘trauma’ opens up a broader array of treatments.

Of course, a name change is no substitute for increased access to therapies, early-life interventions, or indeed more comprehensive education of mental health professionals. However, it can lead to a more nuanced understanding of this condition, which may help improve attitudes amongst the general public and healthcare professionals alike.

References:

[1] NIMH. (2017). ‘Borderline Personality Disorder’. Available online at: Nimh.nih.gov. .

[3] Sansone, R. and Sansone, L. (2013). ‘Responses of Mental Health Clinicians to Patients with Borderline Personality Disorder’. Innovations in Clinical Neuroscience, 10: 39-43.

[2] ten Have, M., Verheul, R., Kaasenbrood, A., van Dorsselaer, S., Tuithof, M., Kleinjan, M. and de Graaf, R. (2016). ‘Prevalence rates of borderline personality disorder symptoms: A study based on the Netherlands Mental Health Survey and Incidence Study-2’. BMC Psychiatry, 16:249

[5] van der Kolk, B. and van der Hart, O. (1989). ‘Pierre Janet and the Breakdown of Adaption in Psychological Trauma’. David Baldwin’s Trauma Information Pages. Available online at: www.trauma-pages.com

[6] Ball, J. and Links, P. (2009). ‘Borderline personality disorder and childhood trauma: evidence for a causal relationship’. Current Psychiatry Reports, 11: 63-68.

[4] Knaak, S., Szeto, A., Fitch, K., Modgill, G. and Patten, S. (2015). ‘Stigma towards borderline personality disorder: effectiveness and generalizability of an anti-stigma program for healthcare providers using a pre-post randomized design’. Borderline Personality Disorder and Emotion Dysregulation, 2:9.

[7] Kulkarni, J. (2015). ‘Borderline personality disorder is a hurtful label for real suffering – time we changed it’. Available online at: https://theconversation.com/borderline-personality-disorder-is-a-hurtful-label-for-real-suffering-time-we-changed-it-41760

About the author

With a background in both history and medicine, our researcher who would like to remain anonymous, is keenly interested in the interface of social science with healthcare. She will be commencing an MSc in Global Health in September.