Borderline Personality Disorder
Final Assignment
NOVEMBER 21, 2022
Nadine Driver
Clinical Assessment & Diagnosis
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Borderline Personality Disorder became an official diagnosable disorder in 1980 when it
was included in the DSM-III (Cambridge University Press, 2020). Surveys have estimated that
the prevalence of borderline personality disorder is between 1.6% and 5.9% of the general
population (Tyborowski, 2020). Personality disorders revolve around firmly believed
maladaptive thinking patterns. The fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders discusses ten disorders that have been classified as personality disorders
( American Psychiatric Association, 2013). Additionally, these disorders were also divided into
subcategories named Cluster A, Cluster B, and Cluster C. Cluster B describes disorders that are
characterized by emotional, dramatic, and/or erratic thoughts or behaviors ( American
Psychiatric Association, 2013). Specifically, Borderline Personality Disorder causes an
individual to experience a consistent pattern of instability within their interpersonal relationships
and their relationship with themselves (Cambridge University Press, 2020). To be appropriately
diagnosed with borderline personality disorder, a client must demonstrate a pervasive pattern of
instability within interpersonal relationships, and self-image, and be marked by impulsive
behaviors that present themselves in early adulthood ( American Psychiatric Association, 2013).
The client must demonstrate at least five of the nine diagnostic criteria. the criteria include
intense fear of abandonment, a pattern of unstable relationships, identity disturbance, suicide
ideation, self-damaging impulsivity, feelings of emptiness, issues with regulating anger, stress-
related paranoid ideation, and mood instability. Borderline Personality Disorder usually appears
during early adolescence and can be present in a variety of situations (Tyborowski, 2020).
Individuals with this diagnosis have a severe fear of abandonment, and often engage in frantic
efforts to avoid being abandoned (Fruzzetti, 2017). These individuals are also prone to very
sudden and dramatic shifts in their view of others, which lead to instability in interpersonal
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relationships (Fruzzetti, 2017). Similarly, shifts in view of themselves also occur, which causes
an identity disturbance in the individual. The identity disturbances that are experienced often
lead to individuals also engaging in suicide ideations or recurrent suicidal behaviors (Gluschkoff,
Jokela, & Rosenström, 2021). To fit into this diagnostic criterion for borderline personality
disorder these individuals display impulsivity that can be damaging to themselves such as
gambling, reckless behavior, or spending binges (Gluschkoff, Jokela, & Rosenström, 2021).
Very often the individuals being diagnosed with borderline personality disorder demonstrate
unstable moods and effects due to their reactivity to interpersonal relationships. Individuals
living with borderline personality disorder most often have issues with regulating their anger
appropriately (Gluschkoff, Jokela, & Rosenström, 2021). Another recurring symptom that would
be reported is chronic feelings of emptiness (Gluschkoff, Jokela, & Rosenström, 2021). Lastly,
when placed under extreme duress individuals with borderline personality disorder often
demonstrate dissociative symptoms or disconnect from their reality (Porr, 2020).
Borderline Personality Disorder is a very difficult disorder to live with for various
reasons including having unbalanced relationships, unpredictability in mood regulation, and
other challenges (Stepp, Pilkonis, & Yaggi, 2019). However, these symptoms are more
manageable when the individual is aware of their diagnosis. Borderline Personality Disorder is a
very complex disorder and unfortunately is very often undiagnosed or misdiagnosed. According
to the National Alliance of Mental Illness, Borderline Personality Disorder is so commonly
misdiagnosed that there is not a consistent prevalence rate for the disorder (Fruzzetti, 2017). As
noted earlier, between 1.6% and 5% of the population is living with a borderline personality
disorder. Even with such a high prevalence rate, this disorder is most often stigmatized which
can lead to individuals being misdiagnosed, undiagnosed, and/ or mistreated (Fruzzetti, 2017).
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Perry Hoffman, founder of the National Educational Alliance for Borderline Personality Disorder
(NEABPD), coined borderline personality disorder as “the leprosy of mental illness” in addition
to being labeled as a disorder with a surplus of stigma attached to it (Porr, 2020). Borderline
Personality Disorder is the most recorded stigmatized psychiatric disorder among mental health
providers and the general society (Porr, 2020). Some of the preconceived ideas attached to
borderline personality disorder include that these individuals are overly dramatic, attention-
seeking, and manipulative (Porr, 2020). The most damaging stereotype for individuals with a
borderline personality disorder is that they are resistant to treatment or untreatable (Porr, 2020).
The impact of this stigmatization is often seen in individuals attempting to suppress their
symptoms and avoid seeking help (Stepp, Pilkonis, & Yaggi, 2019). This can ultimately lead to
further emotional dysregulation. Much of this stigmatization is due to the overly exaggerated
portrayal of borderline personality disorder by the media as being impulsive and dangerous to the
general society (Porr, 2020). Furthermore, a study completed by Innovations in Clinical
Neuroscience revealed that mental health professionals report having higher levels of negative
feelings towards patients with borderline personality disorder, as well as feeling manipulated,
uncomfortable, frustrated, anxious, and apathetic after providing treatment to a patient diagnosed
with borderline personality disorder (Porr, 2020). Many mental health professionals decline to
work with individuals with borderline personality disorder due to the stigmatization that this
disorder is untreatable (Chelminski, Young, & Zimmerman, 2020). Unfortunately, this is because
very few traditional therapeutic techniques are effective for someone with this disorder.
Borderline Personality Disorder is best treated with a specific Cognitive Behavior therapy called
Dialectical Behavior Therapy, which requires specialized training to employ the technique
ethically and productively (Linehan & Wilks, 2018). However, few clinicians engage in this
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training due to the stigmatization that is commonly associated with borderline personality
disorder patients (Porr, 2020).
In addition to being the most stigmatized disorder, borderline personality disorder also is
frequently misdiagnosed (Porr, 2020). Borderline Personality Disorder is most misdiagnosed as
bipolar disorder, but meets several diagnostic criteria for Post Traumatic Disorder, Depression,
anxiety, and other disorders (Chelminski, Young, & Zimmerman, 2020). Although Borderline
Personality Disorder shares similarities with the symptoms of the previously mentioned disorders
the treatment approaches are very different. The consequence of misdiagnosis is the patient
experiencing unsuccessful treatment interventions and unnecessary suffering. Moreover, gender
also plays a role in the misdiagnosis of borderline personality disorder (Porr, 2020). According
to the National Alliance on Mental Health, men tend to be underdiagnosed, and women are
overdiagnosed when it comes to borderline personality disorder (Porr, 2020). Historically
women have always been stereotyped as being emotional or hysterical, and these stereotypes
have led to gross misdiagnoses (Porr, 2020). The occurrence of diagnosing an adolescent with a
borderline personality disorder is new (Tyborowski, 2020). Until recently, clinicians believed
that borderline personality disorder could not be diagnosed until adulthood. Yet, a significant
body of research has revealed that a range of signs and symptoms of borderline personality
disorder can manifest during adolescence (Tyborowski, 2020). However, adolescents are often
misdiagnosed due to demonstrating normal behaviors associated with this period of self-
development such as conflicting feelings regarding sexual orientation, emotional instability, etc.
(Tyborowski, 2020).
As mentioned previously, borderline personality disorder is most misdiagnosed as
Bipolar II Disorder. This is because the two disorders share very similar symptomologies
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including impulsiveness and mood instability (Chelminski, Young, & Zimmerman, 2020).
Unfortunately, the diagnostic criteria for Bipolar II disorder and borderline personality disorder
rely solely on the description of symptoms. The differentiation of these two disorders is a
common diagnostic dilemma (Chelminski, Young, & Zimmerman, 2020). There are no known
biological identifiers for either disorder. Borderline Personality Disorder is specifically a
personality disorder, whereas Bipolar II disorder is identified as a mood disorder ( American
Psychiatric Association, 2013). Nonetheless, the DSM-V in addition to recent studies has
identified considerations to differentiate the two disorders from one another. These
differentiating parameters include sleep disturbance, interpersonal relationship distress, and
episodes of emotional dysregulation (Chelminski, Young, & Zimmerman, 2020). Borderline
Personality Disorder does not report any commonalities in sleep disturbances, but Bipolar II
diagnostic criteria list insomnia as a diagnostic feature of the disorder (Chapman, Jamil, &
Fleisher, 2022). Individuals living with borderline personality disorder and bipolar disorder both
experience issues with interpersonal relationships. However, Borderline Personality Disorder
diagnostic criteria are differentiated from Bipolar II Disorder because the interpersonal
relationship issues resulting from borderline personality disorder alternates between extremes of
idealization and devaluation ( American Psychiatric Association, 2013). While Bipolar II
Disorder symptoms are often the cause of interpersonal relationship distress (Chelminski,
Young, & Zimmerman, 2020). Lastly, Borderline Personality Disorder demonstrates rapid mood
shifts that are short-lived, lasting only hours to days (Chelminski, Young, & Zimmerman, 2020).
Whereas Bipolar II Disorder is differentiated by mood shifts that would last from weeks to
months (Chelminski, Young, & Zimmerman, 2020).
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Borderline Personality Disorder and Histrionic personality disorder are both categorized
as personality disorders in the DSM-V. These two disorders are both described as personality
disorders. These disorders are categorized as Cluster B Personality Disorders, along with
Antisocial Disorder and Narcissistic Personality Disorder ( American Psychiatric Association,
2013). Cluster B Personality Disorders are categorized by impulsive, emotional, and erratic
behaviors ( American Psychiatric Association, 2013). Borderline Personality Disorder and
Histrionic Personality Disorder both share similar diagnostic characteristics such as a rapid shift
in emotions, idealization of relationships, and attention-seeking behaviors (Narcissistic and
histrionic personality disorders, 2020). However, the differentiating parameters include self-harm
and motivation behind impulsive behaviors. Borderline Personality Disorder diagnostic criteria
detail recurrent suicidal or self-harming behaviors due to feelings of emptiness and abandonment
(Chapman, Jamil, & Fleisher, 2022). Whereas Histrionic Personality Disorder demonstrates an
inflated view of oneself, and suicidal behaviors are often an attempt to gain attention from others
(Narcissistic and histrionic personality disorders, 2020). Individuals with Borderline Personality
Disorder often engage in impulsive behaviors to avoid their fear of abandonment and rejection
(Chapman, Jamil, & Fleisher, 2022). On the other hand, individuals with HPD are motivated to
engage in impulsive behaviors to gain attention (Narcissistic and histrionic personality disorders,
2020).
The prevalence of borderline personality disorder is challenging to track as the condition
is often misdiagnosed. Borderline Personality Disorder is so commonly misdiagnosed that the
reported prevalence (1.6% to 5.9%) is not consistent (Tyborowski, 2020). Furthermore,
approximately 75% of individuals diagnosed with borderline personality disorder are women,
even though research suggests that men are equally affected by borderline personality disorder
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(Fruzzetti, 2017). There has been a difference in prevalence depending on the clinical setting.
Outpatient mental health settings tend to have a lower percentage of borderline personality
disorder population within its settings at approximately 10% of the population ( American
Psychiatric Association, 2013). Although in inpatient mental health borderline personality
disorder population make up approximately 20% of the inpatient treatment population
( American Psychiatric Association, 2013). The Substance abuse and mental health services
administration conducted a study that revealed that 50% of participants with borderline
personality disorder abused substances to cope with their uncomfortable feelings (Cambridge
University Press, 2020).
Borderline Personality Disorder is a disorder that severely impacts an individual’s ability
to self-regulate due to real or imagined fears of abandonment ( American Psychiatric
Association, 2013). This loss of self-control can cause an increase in impulsive behaviors,
negative self-thoughts, and intense relationships with others. Chronic difficulties in interpersonal
relationships are a core diagnostic criterion for borderline personality disorder ( American
Psychiatric Association, 2013). This diagnosis directly impacts an individual’s social
functioning. Individuals with Borderline Personality Disorder have intense relationships that are
characterized by alternating feelings of idealization and devaluation (Stepp, Pilkonis, & Yaggi,
2019). Individuals with this diagnosis very often tend to believe someone is either all in or all out
(Gluschkoff, Jokela, & Rosenström, 2021). There is not much room in between for an individual
with a borderline personality disorder. Individuals living with a borderline personality disorder
often characterize their social interactions as more conflicted than those without this diagnosis
(Stepp, Pilkonis, & Yaggi, 2019). In addition to interpersonal conflicts, individuals with a
borderline personality disorder also demonstrate a pattern of self-sabotage or undermining
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themselves right before reaching a point where a goal is about to be realized (Stepp, Pilkonis, &
Yaggi, 2019). Recurrent job losses and interruptions in educational progression are often
examples of this (Stepp, Pilkonis, & Yaggi, 2019).
Borderline Personality Disorder is widely known as a challenging disorder to diagnose,
demonstrated by the high rates of misdiagnoses. Furthermore, there are no biological markers to
assess when discussing borderline personality disorder (Chelminski, Young, & Zimmerman,
2020). However, clinicians have begun creating screening instruments to be able to begin
identifying the likelihood of borderline personality disorder and the need for further evaluation.
The McLean Screening Instrument was developed by Mary Zanarini to assess an individual for
borderline personality disorder (Garder & Miller, 2020). This assessment has ten questions
assessing the DSM-V diagnostic criteria for borderline personality disorder (Garder & Miller,
2020). Each question is worth a total of one point with a score of seven or higher being used as
an identifier for detecting borderline personality disorder (Garder & Miller, 2020).
Additionally, the Personality Diagnostic Questionnaire was also developed to assess an
individual for borderline personality disorder. This assessment is much lengthier than the Mclean
Screening Instrument for Borderline Personality Disorder. This assessment has 100 true or false
questions and is self-administered (Garder & Miller, 2020). The Personality Diagnostic
Questionnaire assists mental health professionals with determining personality disorders
consistent with the diagnoses listed in the DSM-V (Garder & Miller, 2020). The Personality
Diagnostic Questionnaire includes criteria for all personality disorders, and the assessment
identifies the symptoms experienced by the individual to support a diagnosis (Garder & Miller,
2020). Both assessment tools have been tested and concluded to be valid and reliable measures
of borderline personality disorder.
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One of the first identified and most proven methods of psychosocial treatment for
borderline personality disorder is Dialectic Behavior Therapy, which was introduced by Marsha
Linehan in 1993 (Linehan & Wilks, 2018). This treatment requires practitioners to have specific
education and training to employ this technique ethically and effectively (Chapman, Jamil, &
Fleisher, 2022). Dialectal Behavior Therapy is a type of cognitive behavior therapy to address
the symptoms of borderline personality disorder by replacing maladaptive behaviors with
healthier coping skills (Linehan & Wilks, 2018). Although Dialectal Behavior Therapy will not
cure borderline personality disorder, it is the most effective treatment for reducing and managing
symptoms of borderline personality disorder. The research found that approximately 77% of
individuals with a borderline personality disorder that had participated in Dialectal Behavior
Therapy no longer met DSM-V criteria for borderline personality disorder after just one year of
consistent and effective treatment (Linehan & Wilks, 2018). Dialectal Behavior Therapy
involves psychoeducation on four key skills. Those skills are mindfulness, interpersonal
effectiveness, distress tolerance, and emotional regulation. Mindfulness skills are employed to
support the individual in remaining present in the moment (Linehan & Wilks, 2018)t.
Interpersonal effectiveness skills are employed to manage interpersonal relationship conflicts
(Linehan & Wilks, 2018). Distress tolerance skills are employed to support the individual in
coping with stress in healthy ways (Linehan & Wilks, 2018). Lastly, emotional regulation skills
are employed to support individuals in identifying and managing their emotions (Linehan &
Wilks, 2018).
No specific medication has been approved to treat borderline personality disorder.
However, there are psychopharmacological interventions that are available to treat the symptoms
of borderline personality disorder, they are the most common psychotropic medications (Luca,
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Paride, & Francesco, 2021). Furthermore, these medications are often prescribed in various
combinations together. Polypharmacy is common among the borderline personality disorder
community with individuals being prescribed on average 2 psychotropic medications at a time
(Luca, Paride, & Francesco, 2021). Psychopharmacological interventions are often sought out
due to the limited number of clinicians who have the proper training to employ Dialectal
Behavior Therapy (Linehan & Wilks, 2018). However, psychopharmacological interventions are
not recorded to be nearly as effective as Dialectal Behavior Therapy (Linehan & Wilks, 2018).
Additionally, some the psychotropic medications such as antidepressants can cause adverse
effects. These side effects can be as minor as dry mouth and as severe as increased suicidal
thinking (Luca, Paride, & Francesco, 2021).
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References
American Psychiatric Association. (2013). Diagnostic & Statistical Manual of Mental Disorders Fifth
Edition. Arlington: American Psychiatric Association.
Cambridge University Press. (2020). Borderline Personality Disorder. In A. Chapman, N. Hope, & B.
Turner, The Cambridge Handbook of Personality Disorders (pp. 223-241). Cambridge: Cambridge
University Press.
Chapman, J., Jamil, R., & Fleisher, C. (2022). Borderline Personality Disorder. StatPearls Publishing.
Chelminski, I., Young, D., & Zimmerman, M. (2020). Borderline Personality Disorder and the
Misdiagnosis of Bipolar Disorder. Journal of Psychiatric Research, 405-408.
Fruzzetti, A. (2017). Why Borderline Personality is Misdiagnosed. Seattle: National Association of Mental
Illness.
Garder, J., & Miller, S. (2020). Borderline Personality Disorder: Assessment & Diagnosis. Cambridge:
Cambridge University Press.
Gluschkoff, K., Jokela, M., & Rosenström, T. (2021). General Psychopathology Factor and Borderline
Personality Disorder. American Psychiatric Association, 86-92.
Linehan, M., & Wilks, C. (2018). The Course and Evolution of Dialectical Behavior Therapy. The American
Journal of Psychotherapy, 91-110.
Luca, B., Paride, B., & Francesco, N. (2021). Current Clinical Psychopharmacology in Borderline
Personality Disorder. Current Neuropharmacology , 10-19.
Narcissistic and histrionic personality disorders. (2020). In S. W. Dawood, The Cambridge handbook of
personality disorders (pp. (pp. 277–291) ). Cambridge: Cambridge University Press.
Pomeroy, E. (2015). Clinical Assessment Workbook: Balancing Strengths & Differential Diagnosis. Boston:
Cengage.
Porr, V. (2020). Real-Life Consequences of Stigmatization, Misdiagnosis, Misunderstanding, and
Mistreatment of Borderline Personality Disorder. Cambridge University Press, 259-267.
Stepp, S., Pilkonis, P., & Yaggi, K. (2019). Interpersonal and Emotional Experiences of Social Interactions
in Borderline Personality Disorder. The Journal of Nervous and Mental Disease, 481-494.
Tyborowski, B. T. (2020). Adolescent Borderline Personality Disorder: A Diagnosis more Hopeful than
Harmful. Hudson: Bard College.