An article co-authored by Paris5 explores reasons for this misdiagnosis. One is simple confusion on the part of clinicians, due to overlapping symptoms of BPD and BD — especially affective instability.6

Stigma compounds misdiagnosis because of the reluctance on the part of some clinicians to diagnose BPD, preferring the more “innocuous” diagnosis of BD.


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“The term ‘borderline’ is one of the most ‘charged’ diagnoses a person can receive,” Mark Zimmerman, MD, a professor of psychiatry and human behavior at the Alpert Medical School of Brown University in Providence, R.I., told Psychiatry Advisor. “It’s tantamount to receiving a diagnosis of ‘psychiatric cancer.’” Many clinicians feel that their patients will experience less stigma and feel more hopeful with a more “benign” diagnosis.

Others avoid the diagnosis of BPD because they feel helpless in the face of an “untreatable” condition. “Nothing can be further from the truth,” Zimmerman stated. “These clinicians aren’t familiar with recent research7 showing a favorable prognosis in BPD patients who receive appropriate treatments.”

Misdiagnosing BPD as BD does patients an enormous disservice because the medications that are effective in BD are usually ineffective in BPD or, at best, have limited value.8,9

“Only a small subset of  BPD patients benefit from pharmacotherapy,” Zimmerman noted. Worse, inappropriate pharmacotherapy exposes patients to unnecessary drugs and de-emphasizes effective psychotherapies.

The paucity of pharmacotherapies may increase a psychiatrist’s sense of helplessness. But this is based on a misapprehension, said Paris. “If psychiatrists define themselves as ‘medicators,’ they’ll throw up their hands. But if they recognize their role in providing or referring patients to effective psychosocial interventions, their sense of helplessness will diminish.”

Are Patients with BPD ‘Making It All Up?’

“BD is conceptualized as a more ‘medical’ illness than BPD, so people with BPD are held more responsible for their symptoms,” Zimmerman observed. “But their symptoms are their pathology.”

And BPD may actually be a more “medical” condition than previously thought, Zimmerman added. Neuroimaging studies have found neuroanatomical correlates in patients with BPD that differ from those without the condition.10,11,12 But clinicians who are unfamiliar with this growing body of research “think that BPD is an old psychoanalytic myth because it has no ‘biological’ underpinning,” according to Paris. If the condition isn’t “real,” then patients must be inventing their symptoms.