Borderline Personality Disorder and Ethical Practice in Psychiatry - Nancy Potter, PhD
Feel empty, self-destructive, overly angry, and afraid of abandonment? Do you have volatile relationships? Talk to your doctor; you may have Borderline Personality Disorder (BPD).
But it hardly needs people to come forth and suggest that this might be their diagnosis—it’s a popular diagnosis in the DSMs. And it’s especially seen as applicable to women, at least in the United States. Women are far more likely to be diagnosed with BPD than are men; in fact, the DSM-IV-TR reports that 75% of those diagnosed with BPD are women. Mary Ann Jimenez, who has analyzed the psychiatric literature for its evolving thoughts on women, argues that new diagnostic categories continue to reflect a psychiatric orthodoxy where dominant values subjugate women into gender-role conformity. In fact, the picture of the borderline patient as a manipulative, demanding, aggressive, and angry woman is a persistent theme since the diagnosis was included in the DSMs in the early 1980s.
I began taking an interest in the diagnosis and treatment of BPD when I worked as a crisis counselor and would be warned by other workers to avoid so-and-so because “she’s a borderline.” The pejorative tone was hard to miss. Since then, I have taken it upon myself to investigate BPD both in terms of its conceptual features and its bearing on psychiatric ethics.
A personality disorder is considered a structural organization of the personality that is exhibited by a dysfunctional pattern of behavior. A personality disorder is stable over time and, because it is a structural defect in internal organization, it is considered to be inflexible. The inner experience of a personality disorder, along with its outward manifestations, causes the person distress or impairment in functioning.
The borderline personality is considered a severe personality disorder. It is characterized by identity disturbance, feelings of chronic emptiness, impulsive or self-destructive behavior, and unstable intense interpersonal relationships. Other key characteristics include a loss of a sense of self, separate from others, contradictory self-images that are experienced as an inner void and an abundance of mismanaged anger. A significant percentage of the population in the Western world is diagnosed with this personality disorder: 10% of the patients seen in outpatient mental health facilities and 20% of those seen as psychiatric inpatients are diagnosed with BPD. This is a population at risk; as I noted above, patients diagnosed with BPD have a reputation for being extremely difficult to work with. Indeed, clinicians often self-report attitudes of blame, rejection, and a lack of empathy for BPD patients. John Gunderson reports that the most common countertransference feeling of clinicians toward their BPD patients is hate. These facts worry me.
The criteria for diagnosis of BPD raise difficult philosophical and ethical questions. Cultural factors and social norms play a significant role in all of our behaviors and how those behaviors are interpreted, and the diagnosis and treatment of patients with symptoms of BPD are no exception. In fact, the construct of BPD arguably obscures the clinical picture of patients given this diagnosis instead of clarifying it. It is possible that some of our deeply held ideas about the self, identity, anger, and so on lead us astray when we interact with others in distress, attempt to interpret their behavior, and respond to their communications. It is also possible that some of the concepts that we rely upon (such as manipulativity, a label that is ubiquitous in clinical literature) are too vague to serve as a basis of ethically responsive and therapeutically constructive clinical work.
A central task of a philosopher of psychiatry is to press questions such as to what extent the symptoms of the classificatory disorder BPD represent pathology or, instead, cultural disapproval or social disvalue – what is often called the ‘mad or bad’ problem. This problem points to a difficulty in determining whether a given diagnosis is genuinely psychiatric in character or is indicative of embedded moral values that do not belong to psychiatric judgment. This task is crucially important because our attitudes, beliefs, perceptions, and judgments provide the conceptual schemas through which we interpret others; if our conceptual schemas are distorted or faulty, our understanding of others is also likely to be flawed. As I stated above, analysis is needed because the diagnosis and treatment of BPD rest on a number of concepts that are not clearly understood. Particularly interesting are the issues of identity disturbance, anger, interpersonal difficulties, impulsivity, self-injury, and manipulativity, all of which are under-analyzed from a philosophical perspective in relation to BPD. A rigorous examination of these issues will provide valuable insight.
Nancy Potter, PhD is author of Mapping the Edges and the In-between: A Critical Analysis of Borderline Personality Disorder.