As a therapist that specializes in hard-to-treat disorders like chronic depression, chronic anxiety, and personality disorders, I see a lot of patients that have been told they have Borderline Personality Disorder. Sometimes the diagnosis is a great fit and helps a client get the right help they need (like traditional Dialectical Behavior Therapy), but most of the time, it’s just plain wrong.
Borderline PD only makes up about 10% of personality disorders. The diagnostic criteria in the DSM 5 for Borderline Personality Disorder includes a criterion that cause it be misdiagnosed often: recurrent suicidal behavior, gestures or threats, or self-mutilating behavior.
These two criteria are heavily used to give the Borderline PD diagnosis. As a Radically Open Dialectical Behavior Therapist (RO DBT), someone trained in traditional DBT, and a social worker, it’s important to look at the whole person when making a diagnosis.
The number one distinguishing factor between someone with Borderline PD and another disorder is impulsivity. Can a person control their impulses? If they are naturally impulsive (even seen as early as age 4), they are probably undercontrolled. If the impulsivity is not there, most likely the diagnosis is another disorder of overcontrol.
What is impulsivity?
Impulsiveness is the tendency to act on urges without much forethought. Self-control is the ability to inhibit impulses or urges to pursue long-term goals. People with high impulsiveness are undercontrolled. People with high self-control are overcontrolled.
How does this relate to self-harm?
Many people without Borderline Personality Disorder self-harm, but it looks very different in an undercontrolled vs. overcontrolled person. For a person suffering from high emotional dysregulation (i.e. in Borderline PD), the self-harm is usually done to stop an emotion and get another one to start like a relief mechanism. The self-harm is not planned out and can be done on the spot or quickly after the emotion starts. Also people that have Borderline PD may share that they’ve self-harmed with many folks in their circle as a way to get relief or help. Sometimes the impulsive self-harming can lead to injuries so severe that hospitalization and emergency medical attention is needed.
Undercontrol Self-harm
An example of Borderline PD self-harm is a woman who’s boyfriend tells her he wants to take a break from the relationship. She doesn’t want him to go and tells him that “I’m going to kill myself if you leave me” and goes to the kitchen and get a butter knife. She jabs her skin and the boyfriend takes the knife away from her. She runs to the bathroom cry and calls her family and tells them what happened. The boyfriend stays with her all night to calm her down. Everyone is very worried about her.
Overcontrol Self-harm
For overcontrolled leaning people, self-harm looks very different. Usually self-harm is done in private, very few people ever know about it (usually only family and/or a close friend) and it usually doesn’t require medical attention, as the self-harmer attends to the wounds themselves. Many OC clients have never shared that they self-harm with anyone, and they do it in places on their body where no one would see it. Sometimes the self-harm is planned out hours, days or months in advanced.
Two examples of overcontrolled self-harm
The first is a teenage girl, who did not think she did well on a morning AP exam. In order to punish herself for her supposed bad performance, she makes a choice to self-harm after she gets home and has finished all her homework. She makes this choice at 10am and then self-harms at 9.30pm. She cleans her wound and covers it with a bandage and says the cat scratched her. She reveals this to me in our appointment the next day.
A second example is a middle-aged man who doesn’t like his job and feels like people are “out to get him” and “make his life miserable”. Most of the time he feels totally numb and disinterested in life. He has a wife and family. He goes to the hardware store and buys supplies to hang himself. He prepares the rope, but decides that he won’t kill himself until his kids go to college, but feels relief that he has the supplies, so in case things get so bad that he is prepared to do it. He tells no one about this.
Biotemperament Matters
People with high levels of undercontrol act often on their emotions and in public. People with maladaptive overcontrol also feel emotions very intensely but they are not acting on them in public very often and regulate their emotions quickly to not show them externally. In order to find the right treatment, one has to look at biotemperament - can you inhibit and impulse naturally, or do you act on emotional whims?