A borderline personality disorder is a DSM-5 recognized personality disorder. The basis for diagnosing BPD is a clinical constellation of symptoms, including pervasive patterns in self-image, impulsivity, affect, and interpersonal relationships (American Psychiatric Association, 2013). Therefore, BPD can present with abandonment fears, aggression, intense mod shifts, anger problems, suicidal behaviors, self-injurious behaviors, and unstable relationships.
Controversies associated with BPD are due to the stigma surrounding its diagnosis and the nihilistic attitudes of some professionals who encounter many patients with BPD clinical presentations in acute care settings (Campbell et al., 2020). BPD is misunderstood because of the heterogeneity in its presentation (Paris, 2020). The aforementioned symptoms can be nonspecific and can present in various psychiatric illnesses such as schizophrenia, bipolar disorder, and mood disorders.
Constructs of BPD differ in different cultures of the world, and culture dictates what is considered normal or abnormal behavior and thinking. Opposing schools of thought argue that BPD could result from various socio-cultural and environmental contexts. Culture and environment shape how people think and behave (Choudhary & Gupta, 2020). Therefore, different cultures interpret interpersonal functioning, self-image, and emotions differently. Therefore, distinguishing between normal and abnormal behavior, thinking and interactions would rely solely on the caregiver and the clinician’s interpretations. This concept is one of the factors that lead to confusion when diagnosing BPD in different settings of care, thus the controversy.
I acknowledge the scientific basis for the opposing and supporting ideas for BPD. My professional opinion is in support of the diagnosis of BPD. However, clinicians must take care to avoid overdiagnosis due to overenthusiasm, which may complicate the existing controversies. BPD can coexist with other illnesses, such as eating disorders, bipolar disorders, anxiety disorders, substance use disorders, and depression (American Psychiatric Association, 2013; Choudhary & Gupta, 2020). Therefore, a clinician can easily miss the diagnosis due to similarities in the presentations of the coexisting illness.
Evidently, some mental health specialists will intentionally ignore the diagnosis and treat other coexisting illnesses. There is also the stigma that has been associated with BPD and its management (Campbell et al., 2020). No medication has been approved for the treatment of BPD. However, off-label management has shown an excellent therapeutic response to treatment (Levy, 2019). This can make patients who have symptoms and had obtained information from elsewhere before seeing clinicians hopeless and avoid providing accurate information to avoid having this diagnosis. This denial makes the accuracy of its diagnosis debatable.
Therapeutic alliance in therapy is vital in improving the outcomes of the treatment. Patients with BPD present with emotional and mood lability that can interfere with a therapeutic alliance when not anticipated and maintained properly. My crucial strategy when managing patients with BPD will involve supportive psychotherapy. Reassurance, active listening, encouragement, education, and reinforcement are some of the strategies that I would use to build and maintain a therapeutic relationship with these patients. Supportive psychotherapy would work to maintain their mood and support their emotions during the process of treatment.
Lability in mood, instability in social relationships, and impulsivity are some behaviors that implicate these patients in legal problems. These patients’ abilities to shift self-image and emotions can make them manipulative and attention-seeking, as also seen in patients with histrionic personalities. Suicidal behaviors have ethical implications for the caregiver. Ethically, the clinicians are in a dilemma whether to tell these patients their diagnoses, whether to explain their suicidal risks, and whether to involuntarily admit them for inpatient care (Warrender, 2018). The clinicians guiding ethical principles should always aim to do good for the patient. However, attempting to do good in the above situations may cause harm and risk suicidal behaviors among BPD patients.
Personality disorders still pose controversies, ethical and legal implications, and the need for therapeutic vigilance among clinicians and therapists. Borderline personality disorder has been one of the most debated and controversial personality disorders. The controversy about
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