The borderline paradox

To the Editor

Borderline Personality Disorder (BPD) is characterised by low-self esteem, fear of abandonment, emotion dysregulation and maladaptive coping strategies; it commonly occurs on a background of childhood trauma. There is, thus, a sad irony that this patient cohort seems to frequently elicit blame, resentment and desertion by many health practitioners.

While BPD is not currently considered an exclusively post-traumatic phenomenon, the majority of patients with BPD have experienced trauma in the form of physical, emotional or sexual abuse or severe neglect; many have experienced all of the above (Ferguson, 2016). Consequently, they possess a grossly diminished sense of self-worth and struggle with interpersonal relationships. People with BPD often develop maladaptive coping strategies such as self-mutilation, which are unhelpful at eliciting care. The ingrained sense of worthlessness and self-loathing is expounded by these self-injurious behaviours, which can be conceptualised as a means of arousing feeling where emptiness and apathy dominate.

Patients who self-harm evoke frustration and helplessness in treating professionals (Commons Treloar and Lewis, 2008). Unfortunately, the common response is punitive, often with threats to withdraw services. This is ineffective and provides affirmation of the deep-seated sense of worthlessness. A pejorative stance compounds the patient’s poor self-image and erodes their trust in health professionals. People with BPD epitomise the sentiment invoked by the Medical Board of Australia’s Code of Conduct regarding ‘Not prejudicing your patient’s care because you believe that a patient’s behaviour has contributed to their condition’ (Medical Board of Australia, 2014).

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is intended to facilitate an accurate diagnosis and thus optimal treatment of mental disorders. Paradoxically, a DSM diagnosis of BPD may in fact pose a barrier to optimal treatment. The DSM classification system does not link trauma with the diagnosis of BPD, thus creating a disconnect between a common aetiology of BPD and the behaviours characterising the disorder. This disconnect can hinder investigation into the rationale behind the behaviour, foster stigma and negative counter-transference and lead to unfocussed sub-optimal treatment (Ferguson, 2016).

Ultimately, addressing the needs of BPD patients is complex and challenging. However, a more compassionate approach will help to break the reaffirming cycle of worthlessness many patients endure.