Borderline personality disorder has been getting more attention lately, as it should. There are still a lot of misconceptions about it, and it makes sense. If you know of someone with BPD, or you think that’s
what you have, that often makes life more difficult. People tend to fear what they do not understand, especially when it creates difficulties or distress in the first place. I am hoping to share some of the
knowledge I’ve gathered about it in the hope it helps.

In the DSM-5 borderline personality disorder has 9 criteria falling into four general areas: unstable relationships, self-image, emotions, and actions. These symptoms are more extensively covered elsewhere, but just to list them: engaging in frantic efforts to avoid abandonment, having unstable intense relationships, experiencing identity disturbance, impulsivity, recurrent suicidal and self-harm
behaviors, affective instability, chronic feelings of emptiness, intense anger, and stress-related paranoid or dissociative reactions. Someone needs at least 5 of those to receive a diagnosis.

Although on the face of it you just need to count symptoms and call it a day, the diagnosis can be very difficult to make. You can have two individuals with borderline PD diagnosis who only have 1 symptom in common. Another difficulty is that some symptoms commonly occur in other conditions, such as intense anger that can be due to post-traumatic stress disorder, bipolar disorder, depression, head trauma, and a variety of other conditions. Anyone can count symptoms, but the most important part of a diagnosis is the differential, which means finding out what the diagnosis is not. That requires an extensive knowledge of different mental health conditions and ways of distinguishing them despite overlapping symptoms. That’s why your psychiatrist spent most of their 20s and quite a big part of their 30s in school.

Thankfully, there is also a combination of symptoms that can help professionals quickly screen for whether borderline personality disorder is likely to be the primary issue. These are a history of intense relationships with lots of ups and downs, an intolerance of aloneness or fear of abandonment, and history of self-harm. This combination of symptoms is highly sensitive and specific, which means that if all three are present it is very likely to be borderline PD, and if all three are absent it is very unlikely that it is. If there is a hit, we move on to establishing whether other criteria are met, and if not, we are
looking for a more likely explanation, such as a mood disorder or something else.

An accurate early diagnosis of borderline personality disorder is essential. It allows to instill realistic hope and find appropriate treatments. Misdiagnosing it as another disorder may lead to unnecessary pharmacological treatments that have side effects and are not effective, or psychotherapies that are not likely to help, leading to a decline in hope. Despite these challenges, overall course of borderline
personality disorder is improvement over time even in the absence of treatment – that I will cover in the next blog post.