When We Fail to Diagnose BPD, Patients Pay the Price
How diagnostic avoidance, polypharmacy, and our discomfort with personality disorders can stand in the way of effective treatment.
There is something that continues to puzzle me about the way we approach borderline personality disorder (BPD) in mental health care. We have a diagnosis that describes a recognizable pattern of profound emotional and interpersonal suffering, we have decades of research supporting specialized psychotherapies, and we have clinical guidelines that are remarkably consistent about the limited role of medication in treating the disorder itself. Yet many patients continue to spend years in treatment, accumulating psychiatric diagnoses and prescriptions, without ever being offered a coherent explanation for their difficulties or a structured path toward recovery.
I suspect part of the problem is that we are still afraid of BPD.
The diagnosis carries a history of stigma, and understandably so. Patients with BPD have too often been described as manipulative, difficult, attention-seeking, or treatment-resistant, sometimes by the very professionals responsible for helping them. Many clinicians have responded to this history by becoming reluctant to diagnose BPD, disclose the diagnosis, or even consider it in their clinical formulations.
The intention may be compassionate, but when we avoid identifying a treatable disorder because we are uncomfortable with its implications, what exactly are we protecting our patients from?
A diagnosis can be good news
One of the things I find most striking about BPD is the distance between its reputation and what we actually know about its course and treatment. In a landmark 10-year prospective study of 290 patients with BPD, Zanarini and colleagues (2010) found that 93% experienced a symptomatic remission lasting at least two years, while 50% achieved recovery defined more rigorously as both symptomatic remission and good social and vocational functioning. These findings come from a particular clinical population and cannot predict any individual patient's outcome, but they challenge the idea that BPD is necessarily a lifelong condition of unremitting suffering.
We also have evidence that psychotherapy can help. A 2020 Cochrane review found beneficial effects of BPD-specific psychotherapy compared with treatment as usual, with evidence supporting approaches such as dialectical behavior therapy (DBT) and mentalization-based treatment (MBT), although the certainty of evidence and magnitude of benefit vary by outcome.
For patients who have spent years experiencing overwhelming emotions, unstable relationships, intense fears of abandonment, recurrent crises, self-destructive behaviors, or chronic emptiness, receiving an accurate diagnosis can therefore be the beginning of a very different conversation. We can explain that these experiences may be connected, that they form a recognizable pattern, and that other people have struggled with similar difficulties and improved through treatments specifically designed to address them.
In my clinical work, I have often found that one of the most important things we can offer is a credible explanation of what is happening and a treatment plan that makes sense of it. There is something fundamentally different about telling someone that their suffering is understandable and telling them that their suffering is understandable, recognizable, and treatable. I wish we were more comfortable having that conversation.
What happens when we miss the diagnosis?
Consider a patient who has been in psychiatric treatment for years, carrying diagnoses of major depression, generalized anxiety disorder, bipolar disorder, PTSD, or some combination of these. They have tried several antidepressants, perhaps a mood stabilizer or an antipsychotic, and occasionally something for sleep or acute anxiety. Some medications may have helped particular symptoms, but the overall pattern of suffering remains remarkably unchanged. Relationships continue to deteriorate, emotions become overwhelming, crises recur, and the patient returns to treatment feeling that something is fundamentally wrong with them.
The prescriber sees someone who is still suffering despite treatment and reasonably wants to help. Another medication is tried, a dose is increased, or an additional agent is introduced to address a particular symptom. Over time, a complicated medication regimen can emerge without anyone having adequately examined whether the patient's difficulties are better explained, at least in part, by an underlying personality disorder. Diagnostic confusion is a documented concern. In a study published in the Journal of Psychiatric Research, Ruggero and colleagues (2010) examined 610 psychiatric outpatients and found that patients meeting criteria for BPD were substantially more likely to report a previous bipolar diagnosis that was not confirmed by structured assessment. Nearly 40% of the patients with BPD in that sample reported such a history.
That does not mean that bipolar disorder and BPD cannot coexist, or that every patient with multiple diagnoses has been misdiagnosed. It does suggest that clinicians need to be particularly careful when distinguishing enduring patterns of emotional and interpersonal instability from episodic mood disorders. The consequences of getting that distinction wrong can extend well beyond the diagnostic label.
A patient whose difficulties are primarily conceptualized as bipolar disorder may receive years of pharmacological treatment while never being offered psychotherapy targeting the interpersonal and behavioral patterns that continue to generate crises. And when the treatment fails to produce meaningful improvement, we may conclude that the patient needs more treatment, rather than reconsidering whether we have been treating the right problem.
The medication problem
The evidence here is difficult to ignore. A 2022 Cochrane systematic review of pharmacological interventions for BPD found that medications appeared to make little or no difference to overall BPD severity, self-harm, suicide-related outcomes, or psychosocial functioning compared with placebo. The certainty of much of this evidence was low or very low, so the findings should not be interpreted as proof that medication can never help an individual patient. Nevertheless, the review found no convincing evidence that pharmacotherapy effectively treats BPD pathology itself.
The American Psychiatric Association's 2024 practice guideline recommends structured psychotherapy targeting the core features of BPD and suggests that any medication used specifically for the disorder be time-limited, directed at a measurable target symptom, and adjunctive to psychotherapy. It also recommends reviewing and reconciling medications at least every six months, including consideration of medications that may warrant tapering or discontinuation.
The UK's National Institute for Health and Care Excellence (NICE) takes an even more restrictive position, recommending against using medication specifically for BPD or its individual symptoms, while recognizing that medication may be appropriate for co-occurring conditions.
Despite these recommendations, the 2022 Cochrane review notes that psychotropic prescribing remains common among patients with BPD, including the simultaneous use of multiple medications over extended periods. I think this deserves considerably more attention.
Of course, many patients with BPD also have major depression, PTSD, anxiety disorders, ADHD, or other conditions for which medication may be appropriate. Polypharmacy is not automatically inappropriate, and deprescribing should always involve careful assessment and medical supervision. But we should be asking why patients sometimes remain on increasingly complex regimens despite limited improvement in the difficulties that most profoundly affect their lives. My concern is that the failure to recognize BPD, combined with limited access to appropriate psychotherapy, can create conditions in which medication becomes the default response to ongoing suffering.
Each new prescription may be reasonable when considered in isolation. Taken together, however, the medications may reflect a treatment system that continues addressing individual symptoms without sufficiently understanding the pattern connecting them. We should be able to recognize the difference between treating a co-occurring psychiatric condition and repeatedly attempting to medicate the core features of a disorder for which psychotherapy remains the recommended primary treatment.
The limits of validation
I think psychotherapists have our own contribution to make to this problem. There is a phrase that has become increasingly popular in mental health conversations: "It's not you, it's what happened to you."
I understand why it resonates. Many patients have spent years feeling defective, ashamed, or responsible for experiences over which they had little control. Understanding how their emotional responses and interpersonal patterns developed can be enormously relieving, and trauma-informed care has made important contributions to how we understand and respond to suffering. But I worry about what happens when that explanation becomes the organizing principle of treatment rather than the beginning of it.
A patient may have learned to respond to perceived abandonment with desperation, anger, or frantic efforts to preserve a relationship because those responses developed in an environment where connection was unpredictable or unsafe. Understanding that history matters, both clinically and compassionately, but it does not automatically change what happens when the patient experiences rejection today. At some point, we need to examine the thoughts, assumptions, emotional responses, and behaviors that continue to reproduce the very suffering the patient is trying to escape.
This is where therapy can become uncomfortable, for patients and clinicians alike. It is often easier to validate someone's anger toward a parent or former partner than to explore how their current responses may be contributing to recurring interpersonal problems. It is easier to acknowledge that someone has been wronged than to help them confront the possibility that the apology, recognition, or justice they are waiting for may never arrive. And yet a life organized around waiting for other people to change can become a profoundly helpless one.
None of this means that validation is the problem. In DBT, validation is an essential part of treatment, precisely because it creates the conditions in which difficult behavioral change becomes possible. Acceptance and change are two necessary components of the same therapeutic process.
My concern is with a version of therapy that offers understanding without sufficiently helping patients examine the patterns that maintain their suffering, particularly when clinicians are reluctant to introduce a diagnosis that might make those patterns more understandable and treatable. This is a clinical concern rather than a claim that trauma-informed therapy generally produces helplessness. The question is whether we are consistently translating understanding into interventions that improve the patient's functioning and quality of life. There is a difference between helping someone understand why they learned to survive in a particular way and helping them recognize that the same adaptations may now be interfering with the life they want.
The cost of therapeutic avoidance
I suspect some clinicians avoid discussing BPD because they fear damaging the therapeutic relationship, provoking shame, or making patients feel blamed for their difficulties. Those concerns deserve to be taken seriously, especially given the history of stigma associated with the diagnosis. But there is also a risk in withholding a clinically relevant formulation. If we recognize a pattern consistent with BPD but continue describing it exclusively in terms of anxiety, depression, or trauma, we may leave patients without an adequate understanding of why their difficulties keep recurring. We may also fail to refer them to treatments that could make a meaningful difference.
Of course, not everyone with emotional dysregulation has BPD, and an accurate assessment must consider trauma-related conditions, mood disorders, neurodevelopmental differences, substance use, and other possible explanations. We should be equally concerned about overdiagnosis and about applying a stigmatized label without sufficient evidence. But when the diagnosis is supported, avoiding it should not be confused with protecting the patient.
The APA's 2024 guideline specifically recommends a collaborative discussion about the diagnosis and treatment, including psychoeducation. This matters because diagnostic transparency can help patients participate meaningfully in decisions about their care. I would argue that the more compassionate approach is to discuss the diagnosis openly, explain what it means and what it does not mean, acknowledge the limitations of our diagnostic categories, and introduce the evidence for treatment. A patient who understands that their difficulties reflect patterns that can be identified, studied, and changed may begin to see possibilities that were previously unavailable to them.
We need to reconsider what we mean by helping
The problem extends beyond individual clinicians. Specialized treatment remains difficult to access in many communities, insurance reimbursement does not always support the intensity or duration of care that patients need, and clinicians may receive limited training in assessing and treating personality disorders.
When appropriate psychotherapy is unavailable, medication management can become the most accessible form of ongoing psychiatric care, even when it is poorly suited to addressing the patient's primary difficulties. That is a systems problem, and it deserves more attention.
But I also think we need to examine our own clinical habits. Are we comfortable recognizing BPD when it is present? Do we discuss the diagnosis with patients? Do we know what effective treatment looks like, and can we explain why we are recommending it? Are we evaluating whether treatment is producing meaningful improvements in functioning, relationships, and quality of life, or are we simply responding to the latest crisis? And perhaps most importantly, are we willing to challenge patients compassionately when their current patterns of behavior are contributing to their suffering?
There is no contradiction between recognizing that someone developed maladaptive coping strategies through experiences they did not choose and believing that they can learn to respond differently. In fact, that combination of compassion and personal agency is central to several effective approaches to treating BPD. We can acknowledge that a patient was genuinely hurt without requiring them to spend the rest of their life waiting for the person who hurt them to make things right. We can recognize that their emotional responses make sense without assuming that every interpretation or behavior arising from those emotions is helpful.
I would like us to become more comfortable thinking of an accurate BPD diagnosis as an opportunity rather than a verdict. An opportunity to replace years of confusion with a coherent clinical formulation, to reconsider medications that may have accumulated without clear benefit, and to introduce treatments that help people develop greater emotional stability, healthier relationships, and more agency over their lives.
That does not require abandoning trauma-informed care, medication when indicated, or the compassion that should characterize all psychotherapy. It requires us to be more precise about what we are treating and more willing to evaluate whether our interventions are actually helping. I keep thinking about patients who have spent years in treatment, sometimes taking three, four, or five psychiatric medications, while continuing to experience tremendous suffering. How many of them have never been offered a careful assessment for BPD? How many have never been told that their seemingly disconnected struggles might form a recognizable and treatable pattern? And how many might have had a different experience of mental health care if that conversation had happened earlier?
I don't think we have good answers to those questions, but I think we should be asking them.
Because if our reluctance to diagnose BPD means that patients continue receiving treatments that do not adequately address their difficulties, then the stigma we are trying to protect them from may already be shaping their care.
References
American Psychiatric Association. (2024). The American Psychiatric Association practice guideline for the treatment of patients with borderline personality disorder. American Journal of Psychiatry. https://doi.org/10.1176/appi.ajp.24181010
National Institute for Health and Care Excellence. (2009). Borderline personality disorder: Recognition and management (CG78). https://www.nice.org.uk/guidance/cg78
Ruggero, C. J., Zimmerman, M., Chelminski, I., & Young, D. (2010). Borderline personality disorder and the misdiagnosis of bipolar disorder. Journal of Psychiatric Research, 44(6), 405–408. https://doi.org/10.1016/j.jpsychires.2009.09.011
Storebø, O. J., et al. (2020). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, CD012955. https://doi.org/10.1002/14651858.CD012955.pub2
Stoffers-Winterling, J. M., et al. (2022). Pharmacological interventions for people with borderline personality disorder. Cochrane Database of Systematic Reviews, CD012956. https://doi.org/10.1002/14651858.CD012956.pub2
Zanarini, M. C., Frankenburg, F. R., Reich, D. B., & Fitzmaurice, G. (2010). Time to attainment of recovery from borderline personality disorder and stability of recovery: A 10-year prospective follow-up study. American Journal of Psychiatry, 167(6), 663–667. https://doi.org/10.1176/appi.ajp.2009.09081130