Borderline personality disorder (BPD)

The concept of borderline personality disorder (BPD) is thought to have first emerged in the 1930s via the work of Adolph Stern and to have been formally consolidated via the 3rd edition of the Diagnostic and Statistical Manual (DSM; APA, 1980). Contemporary diagnostic criteria as stated in the fifth edition of the DSM (DSM-5; APA, 2013), of which five or more must be present for a diagnosis of BPD to be made, are:

1. Frantic efforts to avoid real or imagined abandonment (Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5)
2. A pattern of unstable and intense interpersonal relationships characterised by alternating
   between extremes of idealisation and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating) (Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5)
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
6. Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper,
   constant anger, recurrent physical fights)
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

In addition to these criteria, a range of attitudes and behaviours are commonly attributed to borderline patients, including attention-seeking and manipulation of staff or others (Day, et al., 2018). There is evidence to suggest that mental health clinicians may view patients with a BPD diagnosis less favorably than those with psychotic disorders (Markham, 2003) and some are open about the fact that they would prefer not to work with this group (Black, et al,, 2011). Bodner, et al. (2011) found suicidal tendencies in borderline patients provoke “antagonistic” judgments rather than empathy. Stern’s original description contains many of the hallmarks of modern conceptualisation of BPD, including references to patients’  ‘hypersensitivity’, ‘deep rooted insecurity’, ‘dependent attitudes’ and ‘demands for pity, sympathy’, and the possibility of negative therapeutic reactions provoking ‘suicidal ideas’ or ‘suicidal attempts’ (Jones, 2023). Al-Alem and Omar (2008) suggest that the term was used from the outset as a diagnosis for those patients who are “hopeless” and in some way difficult for clinicians to relate to. There is very recent evidence that BPD continues to be one of the most stigmatised of psychiatric diagnoses, particularly among practitioners in the very services which are ostensibly intended to help and support people with BPD (Klein, et al., 2022; McKenizie, et al., 2022; Masland, et al., 2023)

Many professionals, activists and academics challenge the construct of BPD, noting that it is a highly gendered diagnosis, with up to three times more women than men receiving the label (Dehlbom, et al., 2022; Glover, 2021), and an increased likelihood of diagnosis in gay or bisexual men (Eubanks-Carter and Goldfried, 2006). Where men are identified as fitting BPD criteria, they tend to be linked to the anger and impulsivity criteria, while women are more likely to be associated with the “emptiness”, “affective instability” and “self-harm/sucidality” criteria (Boazztello, et al., 2024). The diagnosis is commonly applied to women with a history or trauma or abuse (Shaw and Proctor, 2005; Laporte, and Guttman, 1996; Porter, et al., 2020; Boazztello, et al., 2021) with as many of 75% of women admitted to inpatient care for BPD symptoms disclosing childhood sexual abuse (McFetridge, et al., 2015). This important observation has led to a service user/survivor backlash against the diagnosis, expressed online as the hashtag #TraumaNotPD. Related to this, some practitioners and users/survivors have recently begun to question whether BPD diagnoses are often applied to women who are in fact living with undiagnosed autism (Watts, 2023), generating the hashtag #AutismNotPD. Both BPD and autism may present as difficulties with interpersonal relationships and affective instability (Dudas, et al., 2017; May, et al, 2021) but there is little research on how the two might be differentiated.

In studying the sexual relationships of people living with a BPD diagnosis, I am called upon to critically examine the BPD construct. In focussing on the perspectives and priorities of service users/survivors living with the diagnosis, I am also called upon to honour the experiences of those who find utility or comfort in the diagnosis because it explains their feelings and behaviour. I hope to explore the experiences of people with a range of attitudes to their BPD experiences as I seek to draw conclusions about sexual relationships and BPD.