Is It Time to Abolish Borderline Personality Disorder as a Diagnosis?

Borderline Personality Disorder (BPD) is a controversial diagnosis that some psychiatrists have argued “no longer has a place in clinical practice.” The stigma around this label is such that mainstream clinical psychologist Marsha Linehan, leading BPD expert and creator of Dialectical Behavior Therapy (itself the target of criticism from trauma survivors), advises her patients not to disclose their BPD diagnosis in order to avoid mistreatment from healthcare professionals.

A new article published in the International Journal of Mental Health Nursing argues that BPD is not a neutral clinical label, but rather a mechanism of social control that can be used to punish nonconformity, discredit lived experience knowledge, and silence claims of harm caused by diagnosis. The authors, led by Laurence Cobbaert from the University of New South Wales in Australia, contend that what clinicians often interpret as emotional instability, excessive dependence, or interpersonal difficulty as a result of underlying BPD are actually responses to trauma, sensory differences, and structural disadvantage.

The BPD label can revictimize, retraumatize, and undermine patient’s and service user’s credibility. This label can also contribute to coercive treatment, stigma, discrimination, harm, and refusal of care. For these reasons, the authors believe BPD should be abolished as a diagnosis. They write:

A Problematic Diagnosis

Women and LGBTQ+ individuals are more likely to receive a BPD diagnosis. According to the DSM-5, 75% of people diagnosed with BPD in a clinical setting are women. A 2021 study found that sexual minority service users and patients were 59% more likely to be diagnosed with BPD when controlling for factors such as age, gender, and PTSD. A similar study from 2024 found that transgender and gender diverse patients were 3 times more likely to be diagnosed with BPD.

Past research has linked BPD diagnosis to stigma and discrimination, including beliefs that BPD is untreatable, negative clinician attitudes, discrimination in crisis care, being denied treatment, being made to feel like a burden, and damage to self-image. People with this diagnosis have described the label as derogatory and pejorative. A 2022 scoping review reported that 58% of people diagnosed with BPD in their study reported increased anxiety due to discrimination associated with the BPD label, with 71% saying healthcare providers did not take them seriously.

Experts have also argued that the BPD label is often used to discredit patient and service user experiences and testimony. One clinician contends that this issue is especially problematic for women, where the BPD label “clusters women who dissent, who disobey, who resist together, as if these reactions were signs of pathology rather than spirit against the odds.”

One lived experience expert argued that BPD diagnosis oppresses abuse survivors by divorcing their behaviors from the abuse they endured, allowing abusers to evade accountability, pathologizing anger and rage, and allowing abusers to reverse the roles of victim and offender. A 2020 meta-analysis found that people with a BPD diagnosis were nearly 14 times more likely to report childhood adversity and abuse compared to the general population, and more than 3 times as likely compared to people with other psychiatric diagnoses.

Through the lens of “epistemic injustice,” which includes diagnostic labels discrediting the people that receive them, BPD diagnosis could be viewed as a tool for silencing women, LGBTQ+ individuals, and abuse survivors.

A Critical Analysis of BPD

The goal of the current work was to critically examine BPD diagnosis and how it reflects westernized, patriarchal, ableist, sexist, and heteronormative assumptions rather than a universally applicable understanding of an underlying “disease.” The authors also wanted to identify harms related to BPD diagnosis.

Informed by decolonial and feminist scholarship, as well as lived experience, the authors performed a critical discourse analysis around BPD. This method involves examining how people in power use language to shape narratives and exert control over other groups. The authors drew on psychiatric and clinical literature, mental health policies and historic diagnostic texts, research around gender, colonialism, and neurodiversity, first-person accounts, and lived-experience research. They also disclose that they have lived-experience of poor mental health and being harmed by psychiatric treatment which shapes their “ethical refusal of diagnostic neutrality toward BPD.”

The authors begin their analysis by addressing the claim that long-term therapy can lead to “dependence” for people with a BPD diagnosis. They argue that “dependence,” rather than being treated as part of a shared human condition, is pathologized and devalued. This is similar to the way psychiatry framed “hysteria” in the past as a way of pathologizing women’s emotional expression. People marked as “dependent,” often women, are viewed as attention-seeking, manipulative, and clingy. Through this view, expressing needs is reframed as weakness, instability, or moral failure in need of correction, often through coercion. Essentially, people in positions of power decide what constitutes appropriate expressions of need, and justify dismissive attitudes and coercive practices meant to correct anything that falls outside that “appropriate expression.”

The authors argue that BPD language marginalizes people with unique ways of processing sensory information. For example, psychiatry frames suicidality and non-suicidal self injury as an expression of poor attachment to others or problems regulating emotions. This reflects Western, psychiatric assumptions that are not universal. Emerging research has identified sensory processing differences, such as those seen in autism, as strong predictors of suicidality and self injury. The focus on pathological attachment and poor emotional regulation invalidates the experience of overwhelming sensory distress.

According to the authors, people with autism are often incorrectly labeled as having BPD. These patients and service users report having their experiences of overwhelming sensory distress, that can lead to suicidality and self-harm, reframed in BPD language such as “attention seeking,” “manipulative,” and “exaggeration.” Similarly, in therapy such service users have had their sensory issues dismissed as just a manifestation of emotional or relational instability. This is an example of people in positions of power deciding what types of distress are meaningful, and interpreting any departure from that as an inability of patients and service users to understand their own experience.

Attachment theory is often used as a near universal explanation for relationship difficulties common in people with a BPD diagnosis. This theory was largely developed based on research with White, middle-class, Western families and positions the kinds of parenting, caregiving, independence, and emotional expression valued by those groups as the “correct” way to do attachment. However, non-White, non-Western, and collectivist communities can have different values around attachment and emotional expression.

Applying attachment theory to these groups risks labeling culturally different relationships as dysfunctional, and has historically been used to pathologize indigenous families as fragmented, inconsistent, and emotionally neglectful, resulting in forced, often violent removal of indigenous children from their families. This is an example of people in positions of power deciding what kinds of relationships and attachments are healthy, and framing anything else as pathological.

The authors note that while people with a BPD diagnosis often have their experiences scrutinized by mental health professionals, the discipline largely refuses to apply that same scrutiny to its own practices. They point to ECT and antidepressants as dubious treatments with documented harm, overstated effectiveness, and compromised informed consent. This erodes trust in mental health systems and may lead patients and service users to disengage from care. However, when people with a BPD label question treatments that they find unhelpful or harmful, this is framed as proof of their underlying “illness.”

The authors argue that BPD diagnostic criteria is strongly influenced by assumptions about gender, sexuality, and acceptable forms of identity and self expression. Sexual and gender minorities are more likely to endorse BPD diagnostic criteria. However, the authors believe that the stress caused by discrimination, being a minority, and identity conflict are often misunderstood by clinicians as symptoms of a personality disorder rather than as reactions to systemic oppression.

They point to psychiatry’s history of pathologizing LGBTQ+ individuals as a way to police nonconformity. This includes classifying homosexuality as a “sociopathic personality disturbance” in the DSM-I, and “gender identity disorder” in the DSM-IV being framed as a failure to achieve a “stable identity.” This is an example of people in positions of power deciding what identities are healthy, and pathologizing other ways of being.

BPD diagnosis often contributes to the suffering it is meant to explain and address. This label can intensify shame, damage self-worth, undermine credibility, and result in patients and service users being denied care. It can also create a self-reinforcing cycle of harm and invalidation. For example, a patient or service user objects to a treatment as unhelpful or harmful, but rather than considering that objection as a reasonable response to feeling unsafe, harmed, or invalidated, clinicians tend to interpret it as further evidence of the BPD diagnosis.

The authors believe the BPD diagnosis should be abolished in favor of approaches that are capable of addressing distress without relying on a harmful label. This would include treatment approaches that prioritize relational safety, cultural responsiveness, sensory-informed care, epistemic justice, professional accountability, and lived experience leadership. They conclude:

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Cobbaert, L., Maloney, E., Harding, K., & James, S. (2026). Dismantling the diagnostic construct of borderline personality disorder: A critical discourse analysis. International Journal of Mental Health Nursing, 35(2). (Link)