BPD Awareness Month and Understanding Differential Diagnosis
Borderline Personality Disorder (BPD) is often considered one of the most misunderstood and stigmatized diagnoses a person can receive. Living with BPD can be an intense, sometimes painful experience, but is by no means guaranteed to be a hardship forever. Many people find that learning about this diagnosis can help to reduce distress and gain awareness about symptoms.
Talking about BPD inherently involves talking about differential diagnosis, which is the process of distinguishing a diagnosis from others that may present with similar symptoms and have overlapping features. Differential diagnosis also involves ruling out (as much as possible) contextual, developmental, and chemical (substance) influences on symptoms.
This is so important with BPD because many of the symptoms are experienced by most people to a certain degree (this is true of most diagnoses), but a diagnosis of BPD should not be given unless the symptoms are clinically significant - meaning that they impact an individual’s everyday life and functioning to a significant degree, for a significant length of time.
Overwhelmingly, it is people who are assigned female at birth (AFAB) (75%) and people who have experienced significant childhood neglect or trauma (70%) who are diagnosed with BPD. It is also estimated to have a prevalence of 20% in inpatient populations, and research is beginning to show that transgender and gender diverse people are more likely to be diagnosed with BPD than cisgendered people.
When considering a diagnosis of BPD, it’s crucial to think about the social implications that come along with it. While many people feel validated in finally receiving a diagnosis that reflects their distress and life experience, many experience stigma and feel categorized in a way that isn’t helpful or all-encompassing of who they are as an individual. Societal factors including stigma, discrimination, prejudice, sexism, and transphobia may all contribute to the development of the set of symptoms that are known as BPD, and it’s important to see the person behind the symptoms and consider what contextual factors might be a better explanation for someone’s presentation rather than assigning a diagnosis.
A diagnosis is just medical terminology for a group or category of experiences and symptoms: it is a snapshot in time, it doesn’t define everything about a person. And while BPD can be a difficult diagnosis to treat, it doesn’t guarantee a life of hardship as stigma might suggest.
What Is BPD?
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), BPD is marked by “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following” (taken directly from the DSM):
1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
How is BPD Treated?
Dr. Marsha Linehan, who created Dialectical Behavioral Therapy (DBT), currently the only empirically supported treatment for BPD, theorized that the core problem in BPD is actually emotional dysregulation. This dysregulation results from a combination of biological and genetic factors as well as an emotionally unstable childhood environment.
In BPD, emotional dysregulation is believed to come on quicker, be more intense, and take longer to be brought down to baseline.
Traditional DBT is structured includes 3 components:
A skills training group where participants learn skills in the following 5 categories by (usually) two trained therapists as well as several other participants in a similar age group.
Mindfulness: DBT emphasizes the practice of mindfulness, which involves paying attention to the present moment without judgment. This teaches people to observe their thoughts and emotions without feeling the need to react right away.
Emotion Regulation: DBT teaches skills to help individuals identify and regulate their emotions. This includes learning to tolerate distress, reduce emotional reactivity, and increase emotional awareness.
Interpersonal Effectiveness: DBT helps individuals develop healthier interpersonal relationships by teaching assertiveness skills, effective communication strategies, and boundary setting.
Distress Tolerance: DBT teaches coping skills to help individuals tolerate distressing situations without resorting to self-destructive behaviors. This includes learning relaxation techniques, distraction methods, and crisis survival strategies.
Middle Path: DBT encourages individuals to find a balance between acceptance and change. Rather than viewing situations in black and white terms, DBT emphasizes finding a middle path that acknowledges both acceptance of the present moment and the need for change.
Individual Psychotherapy with Skills Coaching Phone Calls
Individuals have a personal therapy trained in DBT that they meet with once or twice a week that is also supplemented with short calls (5-15 minutes) between sessions that are specifically for practicing skills learned in group.
Therapists will do their best to answer calls (and sometimes texts) between sessions after clients have tried to use skills and still need more support or need hands-on help to practice their skills with them. This is done with the idea that when someone is incredibly dysregulated, it’s often much harder to access cognitive skills and knowledge gained during group, so the therapist is there to help the client regulate themselves and to coregulate.
Therapist Consultation Team
True DBT is carried out by a team of therapists that coordinate and communicate with one another in order to create continuity for the client between therapy spaces and tap into group support for both the therapist and the client.
The DBT consultation team will coordinate to ensure that if the client cannot reach their individual therapist for skills coaching or a session, they will be able to reach one of their skills coaches or another therapist on the team in order to receive support. This helps create sustainability of a support network.
Seeking A Diagnosis
While many people feel that they can relate to some of the experiences that come along with BPD, to receive a BPD diagnosis five or more of the DSM criteria (above) must be satisfied and have this confirmed by a licensed mental health professional.
Additionally, a person should not receive a BPD diagnosis if their symptoms are better explained by another diagnosis, life transition, or context – known as “differential diagnosis”.
For example, if someone’s symptoms might be better explained by a substance misuse issue, they would instead receive that diagnosis. It’s also rare and typically contraindicated to diagnose an adolescent or child with BPD, because the above criteria might be better explained by the transition to adulthood and childhood development concerns.
Most importantly: a person cannot diagnose themselves with BPD (and this is true for any diagnosis). This is not in an effort to “gate-keep” care, invalidate one’s individual experience or autonomy, or to generate income for providers – although unfortunately sometimes this can feel like the impact of it on many who do not have the resources to be diagnosed or are unable to have their experiences seen and validated. This is due to the fact that an individual cannot evaluate themselves from an objective lens (even a therapist qualified to diagnose still cannot diagnose themselves!)
Also, a lot of the DSM criteria is difficult to decipher and distinguish on its own, and when you add in factors of differential diagnosis and full assessment, it requires specialized knowledge - this is the training that mental health professionals receive to be qualified to utilize the DSM properly.
If you feel that you do meet the criteria for BPD or any other diagnosis, you can certainly bring this information to a mental health professional. Ultimately, whether you receive the diagnosis or not has to do with whether you fit the criteria listed. If it’s not a fit, that diagnosis is not appropriate; this can be very frustrating for people who are looking for a diagnosis to validate their experience. You may also disagree with your practitioner about whether you are a fit, and they should be able to explain to you why they do not feel that you fit the criteria or what they would instead consider an accurate diagnosis. Even if you do not ultimately receive the diagnosis that you resonate with, know that your experiences are valid whether or not they fit into the medical model.
Living with BPD is not always easy or always hard, and it is possible to find hope and healing with the right support. If you or someone you know is struggling with BPD, know that you are not alone. Contact us today if you’d like to learn more about our services and how we can support you on your journey towards healing and recovery. You deserve validation, understanding, and compassionate care.
At Sage Stone Counseling, we hold that everyone should have the right to mental health care. We focus on providing affirming and safe therapeutic space to marginalized groups of all kinds, and are here to help. If you or a loved one is seeking support from a therapist, consider contacting us today.
