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Spring 2018 Issue

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The Effect of Stigma on the Diagnosis and Treatment of Borderline Personality Disorder

By  Justin Cimring, MD Candidate 2019; Alexander Pattison, MD; Stephanie Peglow, DO, MPH

Personality disorders are a group of mental diagnoses characterized by long-term maladaptive patterns of behavior and cognition, exhibited across many contexts and deviating significantly from those accepted by an individual’s culture. These disorders are frequently associated with significant distress or disability.1 While PDs are widespread globally, their prevalence varies among different countries. Additionally, the most common PD differs from country to country.2 Jackson and Jovev,3 from the University of Melbourne, suggest that culture exerts “manifold influences on personality and PDs,” which may affect the prevalence of PDs in different societies. For example, traditional societies are likely to select for personalities with high dependency traits in order to ensure social cohesion. Conversely, western societies and their emphasis on the success of individuals tend to reinforce narcissism and discourage dependency. Jackson and Jovev further suggest that current events can alter the prevalence of PDs. In war-torn countries, there may be an evolutionary advantage to antisocial PD in the many individuals whose childhood experience was full of lawlessness and brutality. Over time, the increased rates of certain PDs can result in population shift.3

Stigmatization of Borderline Personality Disorder (BPD) is present even within healthcare, and likely has an impact on the treatment and clinical outcomes of those diagnosed with the disorder. Gallop et al.4 found that simply labeling a patient with BPD changed the behavior of the patient’s healthcare providers. This study compared nurses’ responses to hypothetical patients with schizophrenia and BPD. A significant portion of nurses remained sympathetic towards patients with schizophrenia while making contradicting or demeaning statements about patients with BPD. The researchers postulated that the nurses’ behavior may have been a defense mechanism to protect them against perceived manipulation by the patients in addition to the nurses’ personal feelings of helplessness, anger and frustration. This sample might further suggest that when a diagnosis of BPD is present, clinicians form pejorative, judgmental and rejecting attitudes.5

Stigmatization of BPD may effect proper diagnosis.  It has been postulated that the stigma attached to the diagnosis of BPD makes clinicians reluctant to apply it to a patient, leading to the under diagnosis of BPD. An argument can also be made for the over diagnosis of BPD. Many clinicians may equate angry, irritating, demanding, difficult or self-destructive patients to the diagnosis of BPD. In conclusion, further research on the clinical outcomes of BPD and the role that stigmatization plays on both diagnosis and treatment are needed.

References:

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
  2. Sansone RA, Sansone LA. Personality disorders: a nation-based perspective on prevalence. Innovations in Clinical Neuroscience. 2011;8(4):13-18.
  3. Jackson HJ, Jovev M. Personality disorder constructs and conceptualizations. In: Sansone RA, Levitt JL, editors. Personality Disorders and Eating Disorders. Exploring the Frontier. New York: Routledge; 2006. pp. 3–20.
  4. Gallop R, Lancee WJ, Garfinkel P. How nursing staff responds to the label “borderline personality disorder”. Hosp Community Psychiatry. 1989; 40:815-9.
  5. Aviram RB, Brodsky BS, Stanley B. Borderline personality disorder, stigma, and treatment implications. Harvard Review of Psychiatry. 2006;14(5):249-56

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