Borderline Personality Disorder Diagnosis Often Used to Discredit Patient Experiences

A new article uses the concept of epistemic injustice to argue that Borderline Personality Disorder silences patient voices and perpetuates harmful stereotypes.

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Despite 40 years of debate and calls for removal by those with lived experience, Borderline Personality Disorder (BPD) remains a controversial diagnostic category in the DSM-V and ICD-11.

A new article published in Cambridge University Press by Jay Watts from the Center for Mental Health Research at City, University of London, advocates for removing BPD with support from Miranda Fricker’s concept of “Epistemic Injustice.”

The concept illustrates how the BPD label diminishes an individual’s credibility and allows for perpetuating a widespread misunderstanding of their experiences. Applying the lessons from this concept underscores the necessity for movements in psychiatry that value the lived experience and knowledge of service users.

Watts calls for the removal of the label, which she argues would be beneficial for researchers, clinicians, and patients:

“Retaining BPD as a de facto diagnosis keeps us stuck at a deadlock that undermines the voices of patients who have persistently told us this label adds ‘insult to injury.’ Miranda Fricker’s concept of epistemic injustice helps illuminate how this affects subjectivity and speech, hermeneutically sealing patients in ways of thinking that are not evidence-based, resulting in testimonial smothering (altering or withholding one’s narratives) and testimonial quieting (dismissing a speaker’s capacity to provide worthy testimony) that prevent more affirmative explanations.” 

Watts writes that the origin of BPD in DSM-III in 1980 was greatly influenced by dominant social pressures, a trend that has persisted today. She calls its inclusion in ICD-11 a result of “succumbing to the pressure of political lobbying,” resulting in frustrated researchers and clinicians faced with a category that lacks scientific validity and significantly overlaps with other categories. Most notably, however, BPD has significant harmful effects on the individual diagnosed. To emphasize this concern, Watts uses Miranda Fricker’s concept of epistemic injustice.”

She explains how the two primary forms of epistemic injustice, when applied to mental health research, can help conceptualize power dynamics in psychiatry. First, testimonial injustice occurs when a speaker’s credibility is devalued due to harmful bias. Second, hermeneutical injustice occurs when a “collective lack of interpretive resources hinders the understanding of certain social experiences of specific groups.”

Watts provides the example of “Laura,” an individual with lived experience of BPD, to demonstrate the application of the concept. She specifically highlights how her experiences were invalidated and silenced, paired with receiving harmful stereotypes associated with the label. When Laura advocated that her experiences were a result of trauma and challenged her diagnosis, her narrative was quickly discredited. Given that she had been labeled with BPD, a construct that could be applied to many behaviors, particularly ones traditionally associated with and used to pathologize femininity, a clinician can attribute refusing to accept the diagnosis as a symptom.

This seems to be one of the greatest dangers of the construct. BPD pathologizes an individual rather than a condition and frames the “symptoms” as inherent to their character, unlike other non-personality disorders such as depression or OCD. This allows clinicians, society, and even individuals themselves to perpetuate or internalize the harmful stereotypes of borderline personality disorder.

Watt explains the perception of the BPD label as a form of “medicalized victim-blaming,” where clinicians blame an individual for issues arising from external sources such as past traumas or living within a neurotypical world that persistently misplaces problems on the patient.

She concludes the article with calls for the removal of the label, arguing:

“Clear communication can alleviate fears of what might be lost in removing the BPD label, particularly by highlighting the scientific and ethical problems with the construct and by emphasizing the availability of more affirmative alternative explanations to maintain diagnostic rights for those who require them. More validating alternative diagnoses, such as autism, bipolar disorder, premenstrual dysphoric disorder, and complex PTSD, not only better explain the heterogeneity but are free from character assassination, with its devastating deflation of testimonial credibility, although these must be available alongside non-medicalized pathways for trauma survivors should they wish them.”

This article emphasizes the importance of listening to and addressing the real-life experiences of individuals labeled with personality disorders. Watt’s arguments align with the views of many others in suggesting that BPD should no longer be recognized in clinical practice. This is especially important considering the negative impacts of being labeled with the disorder, misdiagnoses based on cultural or gender differences, and research indicating that pharmacological treatments are not effective.

 

 

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Watts, J. (2024). The epistemic injustice of borderline personality disorder. BJPsych International, 1–5. https://doi.org/10.1192/bji.2024.16

 

 

12 COMMENTS

  1. Too late for many of us, even if they do remove the label. I will be 60 and my body and spirit were broken by this label — as well as the ECT and coerced polypharmacy. I was treated terribly at Yale Psych Ward and other wards. I was told things like, “you have borderline personality disorder. That’s why the ECT didn’t work.”. Then immediately the antipsychotic started.

    Now I am about to lose my disability because I don’t have a doctor who will write down on a form that I am an unrecovered borderline. I stopped going to the doctor years ago after finally accepting that it only led to harm.

    I doubt they’ll ever remove the diagnosis. Or they might and replace it with something worse. It’s a very effective weapon against patients who may have a malpractice claim.

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  2. Riddle contends that borderline personality disorder lacks scientific validity. Unfortunately all DSM disorders fit into that category because the “diseases” are voted on by committees, who are often influenced by the pharmaceutical industry.

    There’s no reason to believe that someone diagnosed with BPD would be better off if they were told they have autism, bipolar disorder, premenstrual dysphoric disorder or PTSD. All these “diseases” are problematic.

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    • “There’s no reason to believe that someone diagnosed with BPD would be better off if they were told they have autism, bipolar disorder, premenstrual dysphoric disorder or PTSD.”

      I agree, all the DSM disorders are scientifically “invalid,” and the above mentioned “diseases” tend to come with a lot of forced druggings (mostly anticholinergic toxidrome poisonings).

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  3. “The result is a seemingly endless debate that pleases no one.”

    I don’t know about that. I’ve met some mental health professionals who relished being enabled to define “borderline” any way they see fit.

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  4. “Rather, it is a recognition that the BPD construct often hinders access to help and ripples into unintended areas of life and that, more than 40 years after BPD was first introduced in DSM-III as a patchwork solution that pleased no one, we can do better. Getting rid of the BPD label can be framed as a win-win for all.”

    This is incredibly naive. It assumes that MH professionals are always well intentioned. This is obviously not the case. The fact is that often mental health professionals need a handy weapon in the form of a highly stigmatized and criminalized diagnosis to either threaten a patient with or actually use against a patient who has already suffered some form of malpractice. Borderline personality disorder diagnosis is a very useful “tool” for people who work in the system and they are not going to just give it up.

    It’s no accident that when they write that diagnosis in our medical records the way we are treated in all health care settings is greatly negatively affected, as other articles on this website have already established.

    As long as we pretend that everyone working in the system only ever means well, nothing will ever change.

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  5. Articles like this one and the other recent one saying “why you don’t want a BPD dx” are so full of contradictions as to be meaningless. The other article recommends patients tell their treatment provider that they don’t want the diagnosis where here it says that not wanting the diagnosis is seen as evidence of the diagnosis’ validity.

    How can a patient have “lived experience of BPD” when the diagnosis has no validity?

    “This seems to be one of the greatest dangers of the construct. BPD pathologizes an individual rather than a condition and frames the “symptoms” as inherent to their character, unlike other non-personality disorders such as depression or OCD”

    Is BPD a construct or a condition?

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  6. I use my eyes and see and say, so see if what I say is true. It’s about the truth of health, whether mental, biological, emotional, ecological, social, global. Now, is this so?…..

    We don’t need to try and understand how to be healthy, because imagine asking any creature of nature “how do you keep healthy”? Nature IS freedom IS health. All creatures of nature know how to be healthy and after billions of years of evolution, it would be strange if nature had not nailed down health as the fundamental ground of all sentient life. So the question is not how to find health but how have we destroyed it, in every way conceivable.

    Health and freedom imply each other. Freedom is absolutely essential for health, because only in freedom can intelligence, whether the intelligence of the body or of understanding itself, do what it needs to do in order to stay healthy. On the biological level we call this homeostasis, and we see homeostasis not just in the ecosystem and in the body and cell and atom, we see it in Mother Earth herself and in the solar system and throughout the whole Universe. This is health – balance, and the forces maintaining that balance. The balance is disrupted when a life system is subject to, is being dominated or infected by, something other then itself, which, for Mother Nature and human beings, is social historical accumulation through time – civilization outwardly, and the intellect or socially conditioned thinking mind within. This produces all insanity, i.e. nature distorted, confused, perverted by a social historical process that doesn’t understand it.

    Our minds are destroyed by opinions, conclusions, theories, political convictions, all the useless paraphanalia of our culture, and if you took it all out of the mind there would no longer be a ‘me’ at all. The body has no chance of having the freedom to maintain health in its own wordless, natural way because it has no autonomy, no freedom, and so much is imposed on it that it must adjust to which has nothing to do with its health and which has no understanding of its complex, subtle, wordless needs. Same too with our feelings, emotions, instincts, energies, spirits, or animal spirits, or whatever you want to call these things, which are compromised, deranged, perverted, destroyed, or co-opted by a blind social process that again, has no understanding of the nature or needs of these energetic movements. But whatever we call them, they are facts, not negotiables. Living with them rather then repressing them, observing and understanding them as you would te changing weathers, brings calm and healing to the life energies and this is balance, health.

    Inbalance is over-riding them with aggressive, striving energy generated by social illusions, or depleting them so much that they barely have the energy to lumber on mechanically, with the former inevitably leading to the latter, something psychiatrists call ‘bipolar disorder’ but which they have no understanding of. The Hindu’s understood it 5,000 years ago. They referred to the three gunas, or three states of our lives and consciousness. One is rajistic, meaning fiary, energetic, and stimulants increase this tendency. This is us over-riding our natural needs with aggressive energy. Then there is the tamasic, meaning death, where there is insufficient energy to change and barely enough to go forward, let alone trasncend the past in any way. Then there is balance, where there is a watching of consciousness which naturally corrects any veering off to one extreme or the other. The awareness or attention requires demands the energy of care or passion or interest to maintain it, and much is generated by the natural organism. If we are unhealthy, as society makes us, we are barely able to maintain this posture and are stuck in a pathological egoistic striving or crushed in a destroyed ego which in some way or another has been sloughed off of the social wheal by this cruel, inhuman, unnatural and destructive world.

    What is my expertise? My expertise is perfect and complete, because I am an actual human being, a real one, just like you. There is no other way to understand the Universe then to understand you. How can you understand anything at all if you don’t understand you? An infinity of psychiatrists could never understand you and are merely an infinity of spectacles and brief cases anyway.

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