Post by Admin on Oct 31, 2022 22:25:11 GMT
Fact or Fiction? Dissecting BPD Healthcare Mythology
[Content Warning: Suicide, self-harm, physical assault, psychiatric abuse]
www.psychiatryisdrivingmemad.co.uk/post/fact-or-fiction-dissecting-bpd-healthcare-mythology
Please note: I do not believe “personality disorder” is a valid diagnostic construct, and stand in fierce opposition to its clinical use. Please see my position statement for further information.
Personality disorders are highly contested psychiatric diagnoses, which describe a long-standing pattern of “unusual” or “problematic” thoughts, feelings, and behaviours. There are ten distinct types of personality disorder in the DSM-5: anti-social, avoidant, borderline, dependent, histrionic, narcissistic, obsessive-compulsive, paranoid, schizoid, and schizotypal. The ICD-11 now favours a “scale” of personality disturbance: which starts with none, then moves to personality “difficulties”, and then mild/moderate/severe personality disorder. On top of this, there are a number of “qualifiers”, including detachment, disinhibition, dissociality, anankastia, negative affectivity, and finally, “borderline pattern” which consists of the DSM-5 criteria for borderline personality disorder.
Borderline personality disorder, also known as emotionally unstable personality disorder (BPD/EUPD), is a controversial and contested diagnostic construct [1-5]. It has nine diagnostic criteria, five of which must be present to be diagnosable, these include: intense and unstable relationships; inappropriate anger; mood swings; impulsive or reckless behaviour; self-harm and/or attempted suicide; fear of abandonment; unstable sense of identity; pervasive feelings of emptiness; and stress-related dissociation and/or paranoia. Given that only five of any of the nine criteria are necessary for diagnosis, there exist 256 individually diagnosable presentations of BPD. Numerous lived-experience and academic concerns have been raised about the scientific validity and reliability of BPD as a diagnostic construct; the methods by which it is diagnosed; it’s associated stigma; and the effect the label has on clinician perceptions, treatment and outcomes of patients [6-13]. There is little academic and clinical consensus regarding what BPD “is”, and how the particular cluster of experiences it describes should be categorised. It has been suggested that BPD could be a mood disorder, a neurodevelopmental disorder, a trauma disorder, a collection of misdiagnosed people, and even a diagnostic category created entirely for the purpose of side-lining so-called “difficult” patients [14-21].
BPD is predominantly diagnosed in women and as such, is heavily criticised from a feminist perspective, as being a means of pathologising women who display too many stereotypical “feminine” behaviours (dependency, passivity, displays of emotion etc) and too many stereotypical “unfeminine” behaviours (promiscuity, assertiveness, anger, etc) [22,23]. The majority of people diagnosed with BPD are also survivors of trauma, including a high prevalence of child abuse and sexual violence survivors [24,25]. There is a growing movement against the practice of diagnosing trauma survivors with BPD, given the often devastating consequences of reframing the emotional effects of trauma as a disturbance arising from within an individual's personality [26-29]. People who identify as LGBTQ+ are also overrepresented in BPD populations [30]. Concerningly, research on this phenomenon suggests that irrespective of the persons clinical presentation, clinicians may be predisposed to provide a BPD diagnosis to LGBTQ+ patients [31]. Finally, neurodivergent people, such as autistic people and those with ADHD, are frequently wrongly labelled with BPD, or other personality disorders, often due to poor recognition and understanding of how these conditions present in women and AFAB trans/non-binary people, and stigma related to neurodivergent behaviours, communication methods, and self-harm/suicidality [32-36].
Despite BPD already having a huge collection of diagnostic criteria, it also has a large number of “unofficial” criteria, which includes “manipulative” and “disruptive” behaviour; a “demanding” or “ungrateful” attitude; “attention-seeking”; “dishonesty”; and “non-compliance” [37-41]. If staff perceive these behaviours in a patient, it can lead to a diagnosis of BPD, whether the person meets the actual BPD criteria or not. Concurrently, but in reverse, someone who already has a BPD diagnosis is likely to be perceived as displaying these behaviours, whether the behaviours are present or not [42-44]. These unofficial criteria, when gathered and discussed by healthcare professionals in staff rooms/MDTs/clinical and pseudo-clinical publications/and on social media, form a thick web of BPD mythology, which subsequently informs actual patient care. This web is seemingly impervious to scientific reality. Once a BPD myth has taken hold, it makes no difference how many people speak in opposition of it; how many studies disprove it; or how many official guidelines recommend against it; it will continue to flourish.
All psychiatric diagnoses come with stigma. All people given a psychiatric diagnosis may be victim to discrimination and unpleasant attitudes from the public and healthcare professionals. BPD, however, is one of very few psychiatric diagnoses which not only allows healthcare staff to openly discriminate and voice hideously prejudiced and bigoted opinions about people labelled as such, but actually encourages staff to propagate these views and, further to that, use their prejudice to inform patient care. In many healthcare teams, staff who do not conform to discriminatory attitudes towards patients labelled with BPD are considered naïve, inexperienced, soft, easy to manipulate, and as allowing themselves to be “split” from the team. The BPD myths become clinical “truth” and demand compliance.
I am honestly so tired of hearing these myths from people who should know better. I am tired of seeing people receive abusive and traumatising “care” based on these myths. I have been severely damaged by my own experiences of how these myths informed mine, and my relatives’ “care”. I am haunted by the things I have seen and experienced. I cannot watch another person be neglected or bullied to death based on these myths. These myths are killing people. The information which contradicts and disproves them exists, so why aren’t clinicians listening?? Whatever the reason, I thought I would lay out some of the most prominent BPD healthcare myths here, with opposing views, contradicting information, and evidence which disproves them. I hope it provides a sort of reference library of counterarguments and information for people who wish to oppose these myths, including professionals in their clinical practice, activists, peer supporters, patients, carers, and survivors. This is a living document - if I have not covered a myth you think belongs here, let me know. The same goes for research I have overlooked, or new research not published at the time of writing this, let me know! (in the comments, or via twitter).
Rest in Link
[Content Warning: Suicide, self-harm, physical assault, psychiatric abuse]
www.psychiatryisdrivingmemad.co.uk/post/fact-or-fiction-dissecting-bpd-healthcare-mythology
Please note: I do not believe “personality disorder” is a valid diagnostic construct, and stand in fierce opposition to its clinical use. Please see my position statement for further information.
Personality disorders are highly contested psychiatric diagnoses, which describe a long-standing pattern of “unusual” or “problematic” thoughts, feelings, and behaviours. There are ten distinct types of personality disorder in the DSM-5: anti-social, avoidant, borderline, dependent, histrionic, narcissistic, obsessive-compulsive, paranoid, schizoid, and schizotypal. The ICD-11 now favours a “scale” of personality disturbance: which starts with none, then moves to personality “difficulties”, and then mild/moderate/severe personality disorder. On top of this, there are a number of “qualifiers”, including detachment, disinhibition, dissociality, anankastia, negative affectivity, and finally, “borderline pattern” which consists of the DSM-5 criteria for borderline personality disorder.
Borderline personality disorder, also known as emotionally unstable personality disorder (BPD/EUPD), is a controversial and contested diagnostic construct [1-5]. It has nine diagnostic criteria, five of which must be present to be diagnosable, these include: intense and unstable relationships; inappropriate anger; mood swings; impulsive or reckless behaviour; self-harm and/or attempted suicide; fear of abandonment; unstable sense of identity; pervasive feelings of emptiness; and stress-related dissociation and/or paranoia. Given that only five of any of the nine criteria are necessary for diagnosis, there exist 256 individually diagnosable presentations of BPD. Numerous lived-experience and academic concerns have been raised about the scientific validity and reliability of BPD as a diagnostic construct; the methods by which it is diagnosed; it’s associated stigma; and the effect the label has on clinician perceptions, treatment and outcomes of patients [6-13]. There is little academic and clinical consensus regarding what BPD “is”, and how the particular cluster of experiences it describes should be categorised. It has been suggested that BPD could be a mood disorder, a neurodevelopmental disorder, a trauma disorder, a collection of misdiagnosed people, and even a diagnostic category created entirely for the purpose of side-lining so-called “difficult” patients [14-21].
BPD is predominantly diagnosed in women and as such, is heavily criticised from a feminist perspective, as being a means of pathologising women who display too many stereotypical “feminine” behaviours (dependency, passivity, displays of emotion etc) and too many stereotypical “unfeminine” behaviours (promiscuity, assertiveness, anger, etc) [22,23]. The majority of people diagnosed with BPD are also survivors of trauma, including a high prevalence of child abuse and sexual violence survivors [24,25]. There is a growing movement against the practice of diagnosing trauma survivors with BPD, given the often devastating consequences of reframing the emotional effects of trauma as a disturbance arising from within an individual's personality [26-29]. People who identify as LGBTQ+ are also overrepresented in BPD populations [30]. Concerningly, research on this phenomenon suggests that irrespective of the persons clinical presentation, clinicians may be predisposed to provide a BPD diagnosis to LGBTQ+ patients [31]. Finally, neurodivergent people, such as autistic people and those with ADHD, are frequently wrongly labelled with BPD, or other personality disorders, often due to poor recognition and understanding of how these conditions present in women and AFAB trans/non-binary people, and stigma related to neurodivergent behaviours, communication methods, and self-harm/suicidality [32-36].
Despite BPD already having a huge collection of diagnostic criteria, it also has a large number of “unofficial” criteria, which includes “manipulative” and “disruptive” behaviour; a “demanding” or “ungrateful” attitude; “attention-seeking”; “dishonesty”; and “non-compliance” [37-41]. If staff perceive these behaviours in a patient, it can lead to a diagnosis of BPD, whether the person meets the actual BPD criteria or not. Concurrently, but in reverse, someone who already has a BPD diagnosis is likely to be perceived as displaying these behaviours, whether the behaviours are present or not [42-44]. These unofficial criteria, when gathered and discussed by healthcare professionals in staff rooms/MDTs/clinical and pseudo-clinical publications/and on social media, form a thick web of BPD mythology, which subsequently informs actual patient care. This web is seemingly impervious to scientific reality. Once a BPD myth has taken hold, it makes no difference how many people speak in opposition of it; how many studies disprove it; or how many official guidelines recommend against it; it will continue to flourish.
All psychiatric diagnoses come with stigma. All people given a psychiatric diagnosis may be victim to discrimination and unpleasant attitudes from the public and healthcare professionals. BPD, however, is one of very few psychiatric diagnoses which not only allows healthcare staff to openly discriminate and voice hideously prejudiced and bigoted opinions about people labelled as such, but actually encourages staff to propagate these views and, further to that, use their prejudice to inform patient care. In many healthcare teams, staff who do not conform to discriminatory attitudes towards patients labelled with BPD are considered naïve, inexperienced, soft, easy to manipulate, and as allowing themselves to be “split” from the team. The BPD myths become clinical “truth” and demand compliance.
I am honestly so tired of hearing these myths from people who should know better. I am tired of seeing people receive abusive and traumatising “care” based on these myths. I have been severely damaged by my own experiences of how these myths informed mine, and my relatives’ “care”. I am haunted by the things I have seen and experienced. I cannot watch another person be neglected or bullied to death based on these myths. These myths are killing people. The information which contradicts and disproves them exists, so why aren’t clinicians listening?? Whatever the reason, I thought I would lay out some of the most prominent BPD healthcare myths here, with opposing views, contradicting information, and evidence which disproves them. I hope it provides a sort of reference library of counterarguments and information for people who wish to oppose these myths, including professionals in their clinical practice, activists, peer supporters, patients, carers, and survivors. This is a living document - if I have not covered a myth you think belongs here, let me know. The same goes for research I have overlooked, or new research not published at the time of writing this, let me know! (in the comments, or via twitter).
Rest in Link