Ms. G, a 29-year-old cashier, consulted a psychiatrist about “mood swings,” volatility, depression, and loneliness. Initially, the psychiatrist was empathetic. Encouraged by the psychiatrist’s accepting attitude, Ms. G revealed that during a recent hospitalization, she received a diagnosis of borderline personality disorder (BPD). The psychiatrist became distant and formal during the remainder of the session. Ms. G did not keep her second appointment. Instead, she presented to the emergency department following a suicide attempt.

This is not an uncommon scenario, according to Ron Aviram, PhD, a New York City-based psychologist and an adjunct associate professor at the Albert Einstein College of Medicine in the Bronx, New York.

“Stigma is very common in BPD — not only by the general public, but even among mental health clinicians, who feel they have to create distance to protect themselves,” Aviram told Psychiatry Advisor. Distancing may “inadvertently contribute to the patient’s self-injury and early withdrawal from treatment” by exacerbating existing feelings of unworthiness, self-loathing, invalidation, and rejection, he added.

Numerous studies have shown that mental health clinicians are not immune to negative attitudes toward patients with BPD.1 For example, a recent study of 710 mental health professionals (psychiatrists, psychologists, social workers, and nurses) found that many psychiatrists held negative attitudes toward patients with BPD and reported being “less likely to hospitalize a patient with BPD than a patient with major depressive disorder.”2

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A network of stereotypes and “clinical lore” contribute to this stigma, said Aviram, who is the author of “Borderline Personality Disorder, Stigma, and Treatment Implications.”3 Patients with BPD are seen as “treatment resistant,” “manipulative,” “demanding,” “drama queens,” and “attention-seekers.”

Stigma ensues when “the perception of a negative attribute becomes associated with global devaluation of the person.”4 Clinicians may regard the tumultuous behaviors and stormy emotions associated with BPD as “the nature of the individual” rather than the “nature of the pathology.”3

The Role of Stigma in Misdiagnosis

Ms. G consulted another psychiatrist, this time concealing the prior diagnosis of BPD. The psychiatrist diagnosed her with bipolar disorder (BD) and prescribed lithium, lamotrigine, and an antidepressant. Ms. G experienced modest, temporary improvements in mood but her other symptoms remained unaffected.

One of the most challenging differential diagnoses that psychiatrists face is the distinction between BPD and BD. Patients with BPD are frequently misdiagnosed as having BD, according to Joel Paris, MD, a psychiatry professor at Montreal’s McGill University, and a research associate at the Jewish General Hospital in the city.