To BPD or not BPD

Borderline personality disorder (BPD) is often underdiagnosed or misdiagnosed because of overlapping symptoms with other common disorders, as well as stigmatization issues. Literature indicates people diagnosed with BPD were often either misdiagnosed or diagnosed with a comorbidity of common disorders such as depression, bipolar disorder (BD), ADHD, PTSD, anxiety, and substance use disorder (Baskin & Paris, 2013; Fruzzetti, 2017; Hayward & Moran, 2008; Lohman et al., 2017; Ruggero et al., 2009). Clinicians may focus on addressing the other common diagnoses rather than BPD because of the ease of prescribing medication for the other disorders and stigmatization of BPD (Fruzzetti, 2017; Lohman et al, 2017).  

Baskin and Paris (2013) indicated patients with BPD who complete the Mood Disorder Questionnaire are often inaccurately identified as bipolar due to overlapping of symptoms. Ruggero et al. (2009) mentioned a possibility of up to 40% of people diagnosed with BPD disorder were previously misdiagnosed with bipolar disorder. They indicated the concern of BPD patients being misdiagnosed with bipolar is the ineffectiveness of bipolar medication and therapy for those with BPD; and can often make things worse according to Pascual et al. (2023). Even though therapy and treatment for other disorders do not adequately address BPD concerns, there is indication in research that therapy designed for BPD, such as dialectal behavior therapy (DBT), can also improve symptoms of other mental health concerns (Biskin & Paris, 2013; Pascual et al., 2023; Ruggero, et al., 2009; Temes et al., 2024;). Pascual et al. (2023) suggested focus should be toward the use of evidence-based psychotherapy for BPD, and it should be the primary and initial approach over other treatment or therapy for comorbidities since therapy for BPD will reduce other mental health concerns. Unfortunately, this is not the approach most widely practiced (Biskin & Paris, 2013; Fruzzetti, 2017; Lohman et al., 2017; Pascual et al., 2023). 

There are observed structural and functional changes in the brain related to BPD. However, it is not certain if these changes contribute to the development of the disorder, or a result of the environmental impacts on brain development during childhood. There is a complex interplay between environmental and biological vulnerabilities in regulating mood and stress. Those suffering from BPD are at higher risk of self-harm and suicidal behavior, high reactivity, and intense moods. The impulsive and self-destructive patterns of behavior may be related to the fear of abandonment and being alone. This behavior can also be a result of unrealistic expectations of relationships and shifting blame on the other person with outburst of anger. (Harvard Health, 2026) 

Society has come a long way in approaching and understanding the topics of mental health. However, as previously discussed there is still a widely held stigmatization of BPD patients. I believe one of the biggest reasons is the externalizing tendencies of BPD patients. It’s easier to be sympathetic toward someone suffering from depression, anxiety, or PTSD because of the internalizing nature of the disorders. However, BPD externalizing behaviors can feel like personal attacks or an attempt to “manipulate”. Living with someone who struggles with BPD requires great patience and understanding. It may help to understand the symptoms and source of the development of the disorder. However, it is also important to understand that one person’s mental health is not more important than another’s. A loved-one’s struggle with mental health does not mean others should become a victim of aggressive and abusive behavior when the person refuses to seek appropriate therapy. Harvard Health (2026) also mentioned because of the nature of the disorder, patients typically go through a cycle of seeking help and quitting – but if they stick with it symptoms can be greatly reduced or even eliminated.  

References 

Biskin, R. S., & Paris, J. (2013). Comorbidities in Borderline Personality Disorder. Psychiatric Times, 30(1), 20–25.  

Fruzzetti, A. E. (2017, October 3). Why borderline personality disorder is misdiagnosed. National Alliance on Mental Illness. https://www.nami.org/blog/why-borderline-personality-disorder-is-misdiagnosed/ 

Harvard Health. (2026). Borderline personality disorder.  https://www.health.harvard.edu/a_to_z/borderline-personality-disorder-a-to-z 

Hayward, M., Moran, P. (2008). Comorbidity of personality disorders and mental illness. Psychiatry, 7(3), 102-104. https://doi.org/10.1016/j.mppsy.2008.01.010 

Lohman, M., Whiteman, K., Yeomans, F., Cherico, S., Christ, W. (2017). Qualitative analysis of resources and barriers related to treatment of borderline personality disorder in the United States. Psychiatric Services, 68(2), 167-172. https://doi.org/10.1176/appi.ps.201600108 

Ruggero, C. Zimmerman, M., Chelminski, I., Young, E. (2009). Borderline personality disorder and the misdiagnosis of bipolar disorder. Journal of Psychiatric Research, 44(6), 405-408. https://doi.org/10.1016/j.jpsychires.2009.09.011