Stigma Kills, but BPD Awareness Is at a Crossroads

For the first time this year, I looked forward to May’s Borderline Personality Disorder (BPD) Awareness Month. That’s because we’ve reached a crossroads that could lead to a revolution in how we conceptualize and care for BPD.

I once thought the stigma against BPD would kill me. When I fought BPD in the late 1990s and early 2000s, evidence-based treatments were just beginning to be widely disseminated. The few therapists and psychiatrists willing to work with me after hearing about my suicide attempts just doused me with medications indicated for other psychiatric conditions. I tried to kill myself eight times and turned to drugs to cope with surviving.

BPD afflicts 1.6% of the population, and common symptoms include unstable relationships, recurrent suicide attempts, and erratic moods. During my worst periods with the disorder, I whipsawed between euphoria and desolation. A therapist friend of mine described us as spinning tops that can be knocked over by a flower.

Stigma against BPD abounds. The benighted cultural impression of BPD is still umbilically tied to early, terrible representations like Alex, the bunny boiler in the 1987 film, Fatal Attraction. (The 2023 television reboot wasn’t much better although the bunny lived.) Men on social media gossip about how women with BPD are amazing in bed. Even a group of scientists stooped low with a 2020 peer-reviewed article that was originally titled “Testing the Hot-Crazy Matrix: Borderline Personality Traits in Attractive Women and Wealthy Low Attractive Men Are Relatively Favoured by the Opposite Sex,” in which “crazy” was code for BPD. Despite its air of tawdry unreality, the 2022 Depp V. Heard trial also had real-world consequences for BPD, introducing its stigma to a worldwide audience when the diagnosis was weaponized against Heard.

Online, misperceptions of the disorder can turn nasty. A 91,000-member subreddit for people who have been abused by someone who (allegedly) has BPD is among the first things that many newly diagnosed patients encounter when Googling it. Given that people are often diagnosed with BPD after suicide attempts or other self-harming, being walloped by hatred and misunderstanding during this first search is not just painful. It’s dangerous. Around seventy percent of those diagnosed with BPD attempt suicide at least once, and their lifetime average is 3.4 attempts. Nine to ten percent of people with BPD die by suicide. The disorder significantly lowers life expectancy even when people do not die by suicide due to factors like an increased risk of heart attacks and chronic physical illnesses. In my case, I was diagnosed with systemic lupus erythematosus a few years after my BPD finally calmed.

Last year, in response to an article published in the New York Times about an ultramarathon runner with BPD who had hit his wife, the comment section was overrun with people smearing us with a broad, barbed brush. One identified herself as a mental health professional and boasted that she and her colleagues “run from people with BPD.” It’s true. Studies have found that clinicians are likely to label people with BPD as “difficult” and even “unworthy of care.”

While my BPD went untreated in my early adulthood, emotions tore through me like a prairie fire. Did I behave inappropriately on occasion? Absolutely. So did friends and lovers without BPD. The feelings we have with the disorder are universal, only stunning in their intensity. Even so, many people with BPD agonize quietly. And once I got off drugs, I learned to navigate the fault lines of emotional reactivity and divert my emotions into writing, teaching, and advocacy.

At times, the stigma occludes the vast progress in treatment access and community building achieved over the past few years. While working on my interview podcast, A Real Affliction: BPD, Culture, and Stigma, I’ve talked to writers, researchers, therapists, and advocates, including Dr. Sara Masland, who teaches at Pomona College and researches how BPD stigma creates barriers to care. She has issued a “call to action for psychological science,” in which she and her co-authors made recommendations for researchers and publishers of academic articles about BPD.

I also interviewed Jessie Shepherd, a therapist and author of Millie the Cat Has Borderline Personality Disorder, who explained that she wrote the book to provide not only young but also newly diagnosed people with balanced facts about BPD. Discussing a brainstorming session with her dialectical behavior therapy (DBT) group, she said, “People would sit there and be stumped about the amazing things that come out of borderline personality disorder and the strengths that they have,” which include empathy. “We need better information out here. It can’t just be all negative.”

The news isn’t all negative. For one thing, the idea that BPD is untreatable has been resoundingly disproven by the McLean Study of Adult Development and other longitudinal studies. Most people with BPD do achieve remission although they may face periods of instability. Neuroplasticity means that while people with BPD have brain atypicalities, we can alter them with support from treatment providers and loved ones.

Meanwhile, generalist treatments for BPD—such as Good Psychiatric Management, developed by the late expert, Dr. John Gunderson—are poised to potentially make care far more accessible. They are needed because one researcher estimated that in the United States, there are 5933 treatment-seeking patients with BPD for every clinician certified in an evidence-based treatment for the disorder.

In addition, many people with lived experience are writing, podcasting, and speaking out. I’ve interviewed co-founders of the BPD Society of British Columbia and Emotions Matter, two nonprofits that are making heroic efforts to build nurturing communities for those dealing with the disorder and decrease stigma. In their online peer support groups, I’ve met kind, compassionate people who are struggling mightily to make their lives worth living. As a university educator, I’m thrilled to meet more students with BPD who are receiving accommodations to support their academic success. At the high school level, organizations like DBT in Schools are teaching DBT, the most common evidence-based treatment for BPD, as a preventive measure against suicide generally.

There’s still much work to be done, and not only in reducing stigma. We need to help those marginalized by misconceptions about the disorder, particularly men, BIPOC, and sexual and gender minoritized individuals. We need all evidence-based treatments to be covered by insurance companies. Medical schools must do a better job of delivering stigma-free clinician training because stigma against BPD has been shown to increase during education. We need research into the interaction between BPD and menopause since both BPD and the menopausal transition can cause emotional volatility and suicidality. We should consider how untreated BPD may play a role in the opioid crisis as half to three-quarters of people with BPD suffer from substance abuse problems. And we need more funding for research, advocacy, and treatment—at least ten times more if funding for bipolar disorder, which has similar prevalence, is a guide.

Above all, we need to lower the suicide rate. I asked Dr. Masland if stigma plays a role in its intractability. “The researcher in me says that’s a great research question that we should study. The clinician in me says, yes, absolutely. Even without data, I would stand on a soapbox and shout that out loud.”