Misdiagnosis of borderline personality disorder

Last updated

Borderline personality disorder (BPD) is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, a distorted sense of self, and intense emotional responses, which can be misdiagnosed. [1] Misdiagnosis may involve erroneously assigning a BPD diagnosis to individuals not meeting the specific criteria or attributing an incorrect alternate diagnosis in cases where BPD is the accurate condition.

Contents

Alternative diagnoses

Misdiagnosis of borderline personality disorder (BPD) can occur due to symptom overlap with other mental health conditions and the high rate of comorbidity in personality disorders. [2] Research has shown that having a personality disorder like BPD is a significant vulnerability factor for comorbidity with other mental health conditions. [3] [4] The mood instability characteristic of BPD often leads to confusion with bipolar disorder. [5] Furthermore, the significant role of trauma in BPD complicates its distinction from complex post-traumatic stress disorder (C-PTSD), post-traumatic stress disorder (PTSD) or Autism spectrum disorder (ASD), adding to the challenges of accurate diagnosis. [6] [7]

Complex post-traumatic stress disorder (CPTSD)

Complex post-traumatic stress disorder (C-PTSD), recognized in the ICD-11 but not in the DSM-5, shares core features with BPD, such as emotional dysregulation, interpersonal difficulties, and a negative self-concept, complicating their differentiation. [6] Unique manifestations of these symptoms in C-PTSD and BPD can aid in distinguishing between them; for instance, C-PTSD often involves reactive anger or substance use, while BPD is more associated with self-injury or suicidality. [6] [8] Relationship instability in BPD typically involves rapid shifts between idealization and devaluation, whereas in C-PTSD, it stems from difficulty forming close connections. [9] Additionally, while individuals with BPD may experience fluctuating self-concepts, those with C-PTSD usually maintain a consistently negative self-image. [9] Understanding these differences is crucial for clinicians to accurately diagnose and differentiate between C-PTSD and BPD, especially when comorbid with PTSD, underscoring the importance of comprehensive evaluations.

Autism Spectrum Disorder (ASD)

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by challenges in social communication, repetitive behaviors, and restricted interests, with symptoms varying widely. It is often underdiagnosed or misdiagnosed due to gender differences in symptom presentation and the historical male-centric development of diagnostic criteria. [1] [10] Many people with ASD-traits, particularly women, exhibit social camouflaging behaviors or autistic masking, which can mask core symptoms and lead to alternative diagnoses, particularly borderline personality disorder (BPD). [1] [10] The overlap in symptoms such as emotional dysregulation, intense interpersonal relationships, and identity disturbances, when filtered through a clinician’s lens without properly considering ASD, can lead to a BPD diagnosis, potentially resulting in a misdiagnosis if meanings aligned with BPD criteria are applied rather than exploring alternative explanations during the etiological analysis phase. [1] [10] Furthermore, individuals with ASD, especially women, may not display the overt behavioral phenomena commonly associated with BPD, instead presenting with internalized symptoms like anxiety and depression, or with characteristics such as alexithymia—common co-occurrence in those with ASD [11] —which complicates the diagnostic process by making it difficult to recognize and communicate their emotional experiences. [1] [10] [11]

Bipolar disorder (BD)

Bipolar disorder (BD), a mood disorder characterized by significant mood swings, is categorized into bipolar I, involving at least one manic episode, and bipolar II, characterized by at least one hypomanic and one depressive episode. [12] Both BD and BPD exhibit overlapping features, making differential diagnosis challenging. Affective instability and negative affectivity are core features of both disorders, albeit with variations in their nature and longevity. The difficulty in controlling anger in BPD and the presence of irritability in BD might not be easily differentiated. Impulsivity is a common trait in both conditions; however, in BD, impulsivity may diminish between mood episodes. Additionally, both disorders are characterized by high rates of suicidality and similarly impact social functioning. [13] A small study of 700 participants showed that diagnostic criteria for BPD put patients with BPD at risk of being misdiagnosed with BD, as it found that 40% of those diagnosed with BPD report having been misdiagnosed with BD. [13]

Consequences of misdiagnosis

Misdiagnosis of BPD can result in a number of negative consequences. The reasoning for diagnosis is that of debate within the mental health field. Still, it is primarily looked at as serving the function of providing health professionals of the patient's mental health state, to inform treatment approaches, and to aid in accurately reporting successful treatment approaches. [14] Therefore, misdiagnosis can result in outcomes such as not having access to appropriate psychiatric medications or not being provided evidence-based psychological treatment for their disorders. [15]

Stigmatization

The misdiagnosis of Borderline Personality Disorder (BPD) can have serious negative consequences, particularly in how clinicians perceive and treat patients. [16] Research has shown that when a patient presents with unrelated conditions, such as panic disorder, it may be incorrectly associated with a BPD diagnosis. [16] Clinicians may rate patient's problems and prognosis more negatively than they did when the patient was not given the BPD label. [16] This finding highlights a concerning bias: clinicians may hold negative perceptions of BPD, which can influence their judgments and lead to inadequate or inappropriate treatment. [16] Consequently, a misdiagnosis of BPD can result in stigmatization, reduced quality of care, and a potential overlooking of the patient’s actual condition. [16] This underscores the importance of accurate diagnosis and the careful consideration of how diagnostic labels are used and perceived in clinical practice. [16]

Psychological

Misdiagnosis of BPD can also result in adverse psychological consequences as a diagnosis is used in determining evidence-based treatment approaches used in the therapeutic setting. Treatment approaches such as dialectical behavior therapy and cognitive behavioral therapy for borderline personality disorder are two evidence-based treatments shown to be effective in the treatment of BPD. [13] By providing a misdiagnosis, a person with BPD would likely not have access to these specific treatment approaches, and therefore, their access to evidence-based treatment for their BPD would be delayed until an accurate diagnosis is given. [13] In those with ASD, BPD-related treatment strategies do not address the underlying neurodevelopmental aspects of ASD. [10] Unlike BPD, where emotional dysregulation is typically reactive and situation-dependent, ASD-related emotional challenges often stem from sensory overload or difficulties in social communication. [1] [10] Consequently, treatment plans tailored for BPD, such as dialectical behavior therapy (DBT), may not be as effective for individuals with ASD, who might benefit more from interventions focused on sensory processing and social skills training. [1] [10] Misdiagnosis can also contribute to increased stigma and misunderstanding of the individual's needs, potentially exacerbating mental health issues like anxiety and depression. [10]

Medical

As diagnosis is an essential part of determining what medications to prescribe to a patient or if a patient would benefit from psychopharmacotherapy, being misdiagnosed can have a range of adverse outcomes. Current research has indicated while some prescription medications can help with specific symptoms of BPD, there is no medication proven to decrease BPD symptoms as a whole. [15] In contrast, disorders such as bipolar disorder (BD) have a range of psychiatric medications (e.g., Lithium, anticonvulsants, GABA analogs) being used as a first-line approach to treatment. [17] By providing people with BPD with misdiagnoses such as BD, people with BPD can be subject to receiving medications that will not impact their symptomology and may result in adverse side effects. [15] Alternatively, people who are diagnosed with BPD who may instead have BD or C-PTSD (complex post-traumatic stress disorder) may be deprived of psychopharmacological interventions that would decrease symptoms severity. [15]

Related Research Articles

<span class="mw-page-title-main">Bipolar disorder</span> Mental disorder that causes periods of depression and abnormally elevated mood

Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks. If the elevated mood is severe or associated with psychosis, it is called mania; if it is less severe and does not significantly affect functioning, it is called hypomania. During mania, an individual behaves or feels abnormally energetic, happy or irritable, and they often make impulsive decisions with little regard for the consequences. There is usually also a reduced need for sleep during manic phases. During periods of depression, the individual may experience crying and have a negative outlook on life and poor eye contact with others. The risk of suicide is high; over a period of 20 years, 6% of those with bipolar disorder died by suicide, while 30–40% engaged in self-harm. Other mental health issues, such as anxiety disorders and substance use disorders, are commonly associated with bipolar disorder.

Bipolar I disorder is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. Most people also, at other times, have one or more depressive episodes. Typically, these manic episodes can last at least 7 days for most of each day to the extent that the individual may need medical attention, while the depressive episodes last at least 2 weeks.

<span class="mw-page-title-main">Borderline personality disorder</span> Personality disorder of emotional instability

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, a distorted sense of self, and intense emotional responses. People diagnosed with BPD frequently exhibit self-harming behaviours and engage in risky activities, primarily due to challenges regulating emotional states to a healthy, stable baseline. Symptoms such as dissociation, a pervasive sense of emptiness, and an acute fear of abandonment are prevalent among those affected.

Schizoaffective disorder is a mental disorder characterized by symptoms of both schizophrenia (psychosis) and mood disorder - either bipolar disorder or depression. The main diagnostic criterion is the presence of psychotic symptoms for at least two weeks without prominent mood symptoms. Common symptoms include hallucinations, delusions, disorganized speech and thinking, as well as mood episodes. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses. Many people with schizoaffective disorder have other mental disorders including anxiety disorders.

<span class="mw-page-title-main">Mood swing</span> Extreme or rapid change in mood

A mood swing is an extreme or sudden change of mood. Such changes can play a positive part in promoting problem solving and in producing flexible forward planning, or be disruptive. When mood swings are severe, they may be categorized as part of a mental illness, such as bipolar disorder, where erratic and disruptive mood swings are a defining feature.

<span class="mw-page-title-main">Dialectical behavior therapy</span> Psychotherapy for emotional dysregulation

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis.

Child psychopathology refers to the scientific study of mental disorders in children and adolescents. Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. Mental health providers who work with children and adolescents are informed by research in developmental psychology, clinical child psychology, and family systems. Lists of child and adult mental disorders can be found in the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), published by the World Health Organization (WHO) and in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association (APA). In addition, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood is used in assessing mental health and developmental disorders in children up to age five.

Dissociative disorders (DDs) are a range of conditions characterized by significant disruptions or fragmentation "in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior." Dissociative disorders involve involuntary dissociation as an unconscious defense mechanism, wherein the individual with a dissociative disorder experiences separation in these areas as a means to protect against traumatic stress. Some dissociative disorders are caused by major psychological trauma, though the onset of depersonalization-derealization disorder may be preceded by less severe stress, by the influence of psychoactive substances, or occur without any discernible trigger.

<span class="mw-page-title-main">Complex post-traumatic stress disorder</span> Psychological disorder

Complex post-traumatic stress disorder is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

<span class="mw-page-title-main">Bipolar disorder in children</span>

Bipolar disorder in children, or pediatric bipolar disorder (PBD), is a rare mental disorder in children and adolescents. The diagnosis of bipolar disorder in children has been heavily debated for many reasons including the potential harmful effects of adult bipolar medication use for children. PBD is similar to bipolar disorder (BD) in adults, and has been proposed as an explanation for periods of extreme shifts in mood called mood episodes. These shifts alternate between periods of depressed or irritable moods and periods of abnormally elevated moods called manic or hypomanic episodes. Mixed mood episodes can occur when a child or adolescent with PBD experiences depressive and manic symptoms simultaneously. Mood episodes of children and adolescents with PBD are different from general shifts in mood experienced by children and adolescents because mood episodes last for long periods of time and cause severe disruptions to an individual's life. There are three known forms of PBD: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS). The average age of onset of PBD remains unclear, but reported age of onset ranges from 5 years of age to 19 years of age. PBD is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

<span class="mw-page-title-main">DSM-5</span> 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders, the taxonomic and diagnostic tool published by the American Psychiatric Association (APA). In 2022, a revised version (DSM-5-TR) was published. In the United States, the DSM serves as the principal authority for psychiatric diagnoses. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has practical importance. However, some providers instead rely on the International Statistical Classification of Diseases and Related Health Problems (ICD), and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions. The DSM-5 is the only DSM to use an Arabic numeral instead of a Roman numeral in its title, as well as the only living document version of a DSM.

Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experienced a full manic episode. Otherwise, one manic episode meets the criteria for bipolar I disorder (BP-I).

Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions vary by source and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the sixth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

The mainstay of management of borderline personality disorder is various forms of psychotherapy with medications being found to be of little use.

Cyclothymia, also known as cyclothymic disorder, psychothemia / psychothymia, bipolar III, affective personality disorder and cyclothymic personality disorder, is a mental and behavioural disorder that involves numerous periods of symptoms of depression and periods of symptoms of elevated mood. These symptoms, however, are not sufficient to indicate a major depressive episode or a manic episode. Symptoms must last for more than one year in children and two years in adults.

Childhood schizophrenia is similar in characteristics of schizophrenia that develops at a later age, but has an onset before the age of 13 years, and is more difficult to diagnose. Schizophrenia is characterized by positive symptoms that can include hallucinations, delusions, and disorganized speech; negative symptoms, such as blunted affect and avolition and apathy, and a number of cognitive impairments. Differential diagnosis is problematic since several other neurodevelopmental disorders, including autism spectrum disorder, language disorder, and attention deficit hyperactivity disorder, also have signs and symptoms similar to childhood-onset schizophrenia.

The Bipolar Spectrum Diagnostic Scale (BSDS) is a psychiatric self-rating scale created by Ronald Pies in screening for bipolar disorder (BD). Its initial version consists of a descriptive narrative aimed to capture the nuances and milder variants of BD. Upon revision by Nassir Ghaemi and colleagues, the scale was developed into two sections for a total of 20 questions. The BSDS is widely accepted as an important measure of bipolar disorder alongside other diagnostic tools such as the Mood Disorder Questionnaire and the Bipolar Depression Rating Scale.

<span class="mw-page-title-main">Gender bias in medical diagnosis</span> Concept in medical & psychological diagnoses

Gender-biased diagnosing is the idea that medical and psychological diagnosis are influenced by the patient's gender. Several studies have found evidence of differential diagnosis for patients with similar ailments but of different sexes. Female patients face discrimination through the denial of treatment or miss-classification of diagnosis as a result of not being taken seriously due to stereotypes and gender bias. According to traditional medical studies, most of these medical studies were done on men thus overlooking many issues that were related to women's health. This topic alone sparked controversy and questions about the medical standard of our time. Popular media has illuminated the issue of gender bias in recent years. Research that was done on diseases that affected women more were less funded than those diseases that affected men and women equally.

<span class="mw-page-title-main">Disruptive mood dysregulation disorder</span> Medical condition

Disruptive mood dysregulation disorder (DMDD) is a mental disorder in children and adolescents characterized by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of same-aged peers. DMDD was added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as a type of depressive disorder diagnosis for youths. The symptoms of DMDD resemble many other disorders, thus a differential includes attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, and childhood bipolar disorder, intermittent explosive disorder (IED), major depressive disorder (MDD), and conduct disorder.

References

  1. 1 2 3 4 5 6 7 Darling, Rasmussen P (2023-05-01). "'I was never broken-I just don't fit in this world.' A case report series of misdiagnosed women with higher functioning ASD". Nordic Journal of Psychiatry. 77 (4): 352–359. doi:10.1080/08039488.2022.2112973. ISSN   0803-9488. PMID   37127053.
  2. ↑ Chanen, Andrew M; Thompson, Katherine N (2016-04-01). "Prescribing and borderline personality disorder". Australian Prescriber. 39 (2): 49–53. doi:10.18773/austprescr.2016.019. ISSN   0312-8008. PMC   4917638 . PMID   27340322.
  3. ↑ Korelitz, B. I.; Sommers, S. C. (November 1975). "Responses to drug therapy in ulcerative colitis. Evaluation by rectal biopsy and histopathological changes". The American Journal of Gastroenterology. 64 (5): 365–370. ISSN   0002-9270. PMID   2008.
  4. ↑ Cohen, Patricia; Crawford, Thomas N.; Johnson, Jeffrey G.; Kasen, Stephanie (October 2005). "The Children in the Community Study of Developmental Course of Personality Disorder". Journal of Personality Disorders. 19 (5): 466–486. doi:10.1521/pedi.2005.19.5.466. ISSN   0885-579X. PMID   16274277.
  5. ↑ Kernberg, Otto F.; Yeomans, Frank E. (2013). "Borderline personality disorder, bipolar disorder, depression, attention deficit/hyperactivity disorder, and narcissistic personality disorder: Practical differential diagnosis". Bulletin of the Menninger Clinic. 77 (1): 1–22. doi:10.1521/bumc.2013.77.1.1. ISSN   0025-9284. PMID   23428169.
  6. 1 2 3 Jowett, Sally; Karatzias, Thanos; Shevlin, Mark; Albert, Idit (2019). "Differentiating symptom profiles of ICD-11 PTSD, complex PTSD, and borderline personality disorder: A latent class analysis in a multiply traumatized sample". Personality Disorders: Theory, Research, and Treatment. 11 (1): 36–45. doi:10.1037/per0000346. ISSN   1949-2723. PMID   31259603. S2CID   195757445.
  7. ↑ Darling, Rasmussen P (2023-05-01). "'I was never broken-I just don't fit in this world.' A case report series of misdiagnosed women with higher functioning ASD". Nordic Journal of Psychiatry. 77 (4): 352–359. doi:10.1080/08039488.2022.2112973. ISSN   0803-9488. PMID   37127053.
  8. ↑ Cloitre, Marylène; Garvert, Donn W.; Weiss, Brandon; Carlson, Eve B.; Bryant, Richard A. (2014-09-15). "Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis". European Journal of Psychotraumatology. 5 (1): 25097. doi:10.3402/ejpt.v5.25097. ISSN   2000-8198. PMC   4165723 . PMID   25279111. S2CID   11984913.
  9. 1 2 Brewin, Chris R.; Cloitre, Marylène; Hyland, Philip; Shevlin, Mark; Maercker, Andreas; Bryant, Richard A.; Humayun, Asma; Jones, Lynne M.; Kagee, Ashraf; Rousseau, Cécile; Somasundaram, Daya (2017). "A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD". Clinical Psychology Review. 58: 1–15. doi:10.1016/j.cpr.2017.09.001. ISSN   0272-7358. PMID   29029837. S2CID   4874961.
  10. 1 2 3 4 5 6 7 8 Pires, S; Felgueiras, P; Borges, S; Jorge, J (2023-06-12). "Autism Spectrum Disorder in Females and Borderline Personality Disorder: The Diagnostic Challenge". Cureus. 15 (6): e40279. doi: 10.7759/cureus.40279 . PMC   10336461 . PMID   37448390.
  11. 1 2 Shah P, Hall R, Catmur C, Bird G (August 2016). "Alexithymia, not autism, is associated with impaired interoception". Cortex; A Journal Devoted to the Study of the Nervous System and Behavior. 81: 215–220. doi:10.1016/j.cortex.2016.03.021. PMC   4962768 . PMID   27253723.
  12. ↑ "Bipolar and Related Disorders", Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, American Psychiatric Publishing, Inc, 2013, doi:10.1176/appi.books.9780890425596.057204, ISBN   978-0-89042-559-6 , retrieved 2020-10-15
  13. 1 2 3 4 Ruggero, Camilo J.; Zimmerman, Mark; Chelminski, Iwona; Young, Diane (2010). "Borderline personality disorder and the misdiagnosis of bipolar disorder". Journal of Psychiatric Research. 44 (6): 405–408. doi:10.1016/j.jpsychires.2009.09.011. ISSN   0022-3956. PMC   2849890 . PMID   19889426.
  14. ↑ Sartorius, Norman (2015). "Why do we need a diagnosis? Maybe a syndrome is enough?". Dialogues in Clinical Neuroscience. 17 (1): 6–7. doi:10.31887/DCNS.2015.17.1/nsartorius. PMC   4421902 . PMID   25987858.
  15. 1 2 3 4 Paris, Joel; Black, Donald W. (2015). "Borderline Personality Disorder and Bipolar Disorder". The Journal of Nervous and Mental Disease. 203 (1): 3–7. doi:10.1097/nmd.0000000000000225. ISSN   0022-3018. PMID   25536097. S2CID   2825326.
  16. 1 2 3 4 5 6 Lam, DC; Salkovskis, PM; Hogg, Li (2016). "'Judging a book by its cover': An experimental study of the negative impact of a diagnosis of borderline personality disorder on clinicians' judgements of uncomplicated panic disorder". British Journal of Clinical Psychology. 55 (3): 253–68. doi:10.1111/bjc.12093. PMID   26212734.
  17. ↑ Thompson, Kevin. (2007). Medicines for mental health : the ultimate guide to psychiatric medication (2nd ed.). North Charleston, S.C.: BookSurge Pub. ISBN   978-1-4196-6954-5. OCLC   226095173.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.