In recent years, Borderline Personality Disorder is beginning to grow in recognition, having been included in the DSM III since 1980. We’re beginning to see it reflected in the media, such as the portrayal of BPD in Crazy Ex-Girlfriend. However, despite individuals with BPD showing symptoms since young adolescence and often entering therapy early, most of them are not diagnosed until their mid 20’s. This can have quite a devastating effect in those early years and coming to grips with the disorder, so let’s take a look at why this is happening!

Is BPD diagnosed late?

Some consider a diagnosis in early adulthood to not be late at all, as that’s when you’re believed to have grown into your 'true state'. It removes the possible influence of puberty and the bucketload of hormones it brings, as well as the turbulence and social influences of high school. But is it right to remove some social pressures from the diagnosis of BPD, for doesn’t the individual’s reaction to these sum up a great deal about the personality disorder and how it affects them?

I consider the diagnosis of BPD to be late given how early it starts affecting you. Most mental illnesses start brewing in adolescence and early adulthood, but many can also appear later in time when different pressures or stimuli are presented. Borderline Personality Disorder differs in that it can start affecting the individual earlier than others usually do. The coping mechanisms that accumulate to BPD are often learned in childhood, and begin to have adverse effects soon after. Throughout adolescence and into early adulthood, the personality disorder may be running rampage, and thoroughly affecting their life.

If you look at the symptoms of BPD, as well as the numerous disorders that can accompany it, it would suggest serious harm to life satisfaction. So why are we not catching it? Or rather, why are we not diagnosing it? For those are two very different things. Whether a clinician is choosing to not diagnose, or missing the possibility of BPD entirely.

Is BPD diagnosed late due to DSM criteria?

The DSM V indicates that the patterns of BPD behaviour begin in adolescence or early adulthood, if not earlier. And the DSM V, just like the DSM IV preceding it, permits the diagnosis of a personality disorder (except antisocial personality disorder) in someone under 18 years if the symptoms have been present for at least a year, and are “pervasive, persistent and unlikely to be limited to a particular developmental stage or another mental disorder”. This suggests that we could be diagnosing a BPD individual from adolescence, once the symptoms are present and impacting their life prominently.

But there are several issues with this.

Firstly, knowing that it isn’t limited to a particular developmental stage. If we take a look at several of the key components of BPD, some could be misconstrued as part of adolescent development. Unstable relationships? Well, we often portray teenagers as having numerous quick relationships, idolizing a person and then hating them. An unclear and shifting self-image? Teenagers are trying to find themselves, they can go through numerous phases as they try to understand who they are. I still don’t even know! Mood swings and extreme anger, the epitome of the misunderstood adolescent. And impulsive behaviours, but I doubt many of us didn’t binge drink or do impulsive things during those “golden years”.

I’m not saying that every teenager has BPD, nor that BPD symptoms can be brushed off as teenage angst. I’m just saying that it can be hard to know which is which. I guess the truth would lie in the remaining symptoms, including self-harm, feelings of emptiness, fear of abandonment and loss of contact with reality. Particularly if a teenager is self-harming, there is something going on. Whether it’s bad mental health or a mental illness, it needs to be addressed and taken seriously.

A little personal touch here. When I was diagnosed at 22, I was informed by my therapist that my previous clinician had actually written on my file that they believed BPD to be the cause. They had hesitated in telling me or investigating it further as they feared I hadn’t fully developed my personality yet or the effect of BPD stigma. I was angry at first. Since being diagnosed and getting the appropriate treatment, I have seen so much improvement in my mental health and ability to deal with my disorder, despite a lot of situational difficulties during this period. If they had diagnosed me two years prior when they wrote that note, could I have gained back those two years I felt lost to my mental illness? Would I have been able to understand myself better as I do now? We can’t know.

The misdiagnosis of BPD

But as mentioned in that DSM V extract, another requirement is being certain that it isn’t a different mental disorder, and therein lies one of the biggest BPD struggles. BPD is often composed of several mental illnesses, all stuck together like potatoes mashed in a bowl - apologies, I’m rather hungry at the moment. And with this, comes the misdiagnosis of BPD.

Someone could be receiving treatment for their addiction, or eating disorder, for a long period of time, without their therapist realising that BPD is actually the root of the issue. BPD is often missed, given how new the disorder is, and instead the individual is given another label, or several! Another reason is that there is so much stigma still surrounding BPD and other personality disorders, even with professionals who will then hesitate to diagnose it, or not consider it a valid diagnosis. I can’t speak for others, but I far prefer my neater personality disorder diagnosis than the years leading up to it with the eating disorder, mood disorder and anxiety disorder package.

It’s been shown that BPD is most commonly misdiagnosed as Bipolar Disorder, Type 2. This is primarily due to similarities between symptoms, including impulsive behaviour, suicidal thoughts and intense emotions. But despite these similarities, there are a lot of differences, particularly in how to handle and treat the disorder.

The BPD label

Research shows that many healthcare workers delay diagnosing a personality disorder, like BPD, due to the fear that the individual will latch onto it, and continue their symptoms. A personality disorder can be confusing given how it has infiltrated an individual’s personality, and many will struggle to remove that, or fear removing it. You spend years thinking these are your traits, your habits or flaws, and then you’re told that they’re not you at all? They’re a disorder that is keeping you from who you are. It’s scary, and feels like losing the identity you know.

BPD is not treatable

Before 1991, there was no published evidence of BPD being treatable. And even past that point, few were showing signs of improvement. The worst part is that clinicians were blaming BPD individuals for not getting better, seeing it as a choice they were making, as it was easier than acknowledging that they hadn't figured out how to correctly help them. Even now, evidence shows a proportion of professionals still think BPD is not treatable, and will thus avoid giving that diagnosis. But we've got to remember, this doesn't mean that the person doesn't still have BPD, simply that they don't know it, and they're not being treated correctly.

BPD is for women

And now we see why plenty of men are being diagnosed with BPD for too late, or at all! There is a weird myth that only women, or mainly women, have BPD. But this is completely false! Actually the epidemiological rates of BPD in males and females are almost equal, the only difference is that females seem to be over-diagnosed and males underdiagnosed. This stems from women being overrepresented in most studies and treatment.

We can probably trace this back to where most gender mishaps go, the ideas of masculinity and femininity. Women are “emotional” and “hysterical”, and that fits BPD pretty well. Furthermore men have to be strong, and not admit their weakness, which sadly makes them avoid speaking up and seeking treatment. But mental illness isn’t about gender, it’s about seeking help and getting the appropriate treatment. Starting with the correct diagnosis.

Why should we diagnose BPD earlier?

Some studies have shown that early treatment of the disorder during a critical development period can hugely help the individual. It reduces the effect of BPD and how inexplicably it becomes linked to personality, as the individual is still working out their personality. Furthermore, it allows you to be prepared for more difficult periods, such as adolescence, and have coping mechanisms in place.

And less scientifically, you don’t feel like you lost time. You don’t spend years unhappy, hurting yourself or others, and with an increasing list of regrets. It can be difficult for BPD individuals, as they’re told adolescence/early adulthood are one of the best times of their life, yet they’re already struggling heavily.

It’s very chicken and the egg! Many fear that diagnosing a teenager with BPD will worsen their condition due to stigma, but doesn’t this in turn create stigma by suggesting it is something shameful to diagnose? And others fear that diagnosing BPD will make the individual lean into these symptoms, further wrap their identity around it. But the disorder is already in that prime spot, so wouldn’t knowledge of that help to extract it from your own personality?

What you can do, starting from today, is reduce that stigma yourself. We have the power in us, and it’s small changes. It’s recognising your own mental health and giving it the attention it deserves. It’s listening to someone’s diagnosis without judgement, and supporting them. It’s doing your research, being correctly informed so you don’t perpetuate stigma and stereotypes. It’s supporting series, books, films and other media outlets that feature mental illness correctly, and that open the discussion. It’s recognizing that mental illness, BPD, is here, whether we like it or not, so let’s welcome individuals and their story.