The Social Construction of Borderline Personality Disorder

Medicalisation is the redefinition of deviance as illness (J. Busfield 2017: 759). It is a diffusion of power and a means of social control. The de-medicalisation of certain mental health disorders, such as homosexuality, reveals the temporal relationship between our conception of deviance and the dominant regime of truth. What is pathological and what is normal shift across time and space, contingent on the mandates of hegemony (P. Bjorklund 2009: 17).

An exploration of Borderline Personality Disorder (BPD) is epitomic of this. The disproportionate representation of women diagnosed with BPD, and its feminised aetiology, is both a preservation and symptom of patriarchy. However, its medicalisation can also act to legitimate BPD within the parameters of science and healthcare - unveiling the structures that perpetuate female suffering. Therefore, a pluralistic approach of the medicalisation of BPD can engender inquiry into the conditions and consequences of an oppressive, misogynistic society.

In Foucault’s analysis, 18th century Enlightenment marked the collapse of the Sovereign where previously power, discipline, and control rested on a single monarch decreed by God (M. Foucault 1975). Modern governmentality saw the diffusion of power where discursive institutions naturalised norms and ideals that upheld existing social arrangements. Those that were unable to fulfill the roles and expectations of civilisation were marginalised. Medicine, especially psychiatry, replaced religion becoming one of the most powerful extralegal institutions of social control (S.H. Sulzer 2015: 6). This is mirrored in the medical incarceration of the “insane” during the Age of Reason that was preceded by a professional diagnosis. Problems of illness, both somatic and psychic, fell under the jurisdiction of the physician and the broader medical body, irrespective of its capacity to deal with it effectively (P. Conrad 2013: 205). The language of psychiatry therefore became a “monologue of reason about madness” (M. Foucault 1965: xi). An archipelago of the secure institutions of expert knowledge cast a psychiatric gaze over conceived deviances, medicalising social abnormalities as an apparatus of control (N. Rose 2006: 466).

The Diagnostic Statistical Manual (DSM) emerged in 1952 as a standardising nosological tool and a central infrastructure of medicalisation, despite ambivalence on universal diagnoses. An American psychiatrist Karl Meninger boldly asserted that classifications should be abandoned all together claiming them arbitrary and credulous (A. Scull 2019: 278). A carefully controlled study revealed that agreement between two American psychiatrists intrastate barely reached 50 per cent (A. Scull 2019: 278). Regardless the DSM’s use proliferated, contextualised by the consolidation of Western capitalism in the 1970s. The accompanying pharmaceutical revolution increasingly individualised risk and illnesses, seen as having genetic and individual causes, were mediated by self-regulatory and consumptive behaviours. Consequently, allopathic treatments were increasingly prescribed, reliant on clear diagnostic delineations and perpetuated by medicine’s attachment to both science and prestige (J. Busfield 2017: 762). It is reductionist to claim that scientific advancements within healthcare are a sole engine of neoliberalism, however its implications carry the vestige of cultural and economic histories. Personality disorders present an additional contention and tenuous relationship with diagnostic validity as they do not include obvious organic malfunctioning, but are detected by interpersonal and behavioural effects (N. Manning 2000: 622). Hence, they are more susceptible to social interpretation and represent an embodiment of the ethnopsychological assumptions about the ideal self, the Other, and the modes of experience and behaviour that constitute abnormality (P. Bjorklund 2006: 16).

The latest reiteration of the DSM-V (2013) describes Borderline Personality Disorder (BPD) as a severe form of behavioural disorganisation (S.K., Cahn 2014: 263). It is characterised by a pervasive pattern of instability affecting: interpersonal relationships; self-image; and affects, and marked impulsivity that is self-malignant. A diagnosis is reached when five or more of the following criterion is met (DSM-V 2013: 663):

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.

Since the 1970s, BPD ceased to be gender neutral. An estimated 77 per cent of patients diagnosed with BPD are women (S.K. Cahn 2014: 259). This can be explained by the feminised symptomatology of BPD being a corollary of cultural imperialism, where female bodies are socially regulated according to dominant gendered ideologies. Tellingly, during this decade the tenets of second wave feminism grew in salience, concerned with sexual autonomy and the power imbalances in clinical encounters. Feminists fought to legitimate female sexuality and intimately linked the awareness and protection from sexual abuse (S.K. Cahn 2014: 264).

For example, “sexual impulsivity” (DSM-V 2013: 633) has specific expressions in relation to the BPD female patient, informalised as promiscuity or hypersexuality. In a controversial 1989 article on BPD and patient-therapist sex, psychiatrist Thomas Gutheil claimed that borderline patients “possess the ability… to seduce, provoke, or invite therapists into boundary violations of…countertransference” (S.K. Cahn 2014: 272). Sharing this sentiment was psychiatrist Harold F. Searles, describing the symptoms of a “borderline woman” as “coquettish” and “seductive” in manner (S.K. Cahn 2014: 272). The clinical interpretation of “sexual impulsivity” as hypersexual and promiscuous, positions women with BPD as having a moral rather than organic illness (O. Bonnington & D. Rose 2014: 11). This is symptomatic of patriarchy manifest in the prevailing culture of sexual violence and victim blaming against women (P. Conrad 2013: 202).

Furthermore, the causes of BPD and its significant comorbidity destabilises the epistemic quality of the DSM that avows for objective specificity. Historically, “borderline” was a descriptor for a pathological purgatory: between sanity and insanity, neurosis and psychosis , on the border and somewhere in-between (P. Bjorklund 2009: 5). Most clinicians and theorists characterise BPD in part by its very indeterminacy and paradoxical nature. The dialectics of the symptoms vary from one contradictory extreme to the other – hence the psychodynamic therapy for BPD being named Dialectical Behaviour Therapy (DBT) (P. Bjorklund 2009: 5). The U.S. Department of Health and Human Services Report to Congress on Borderline Personality Disorder (2010) cite significant comorbidity of BPD with other psychiatric disorders such as: major depressive disorder; attention deficit hyperactivity disorder (ADHD); eating disorders; and social phobia (S.K. Cahn 2014: 270). This reveals a classification that represents gendered abnormality rather than a precise aetiology. Symptoms of BPD such as impulsive sex and aggression are shared with ADHD, a disorder that has a male to female diagnostic ratio of 4:1 (U.P. Ramtekkar et al. 2011: 217). These behaviours are coded as masculine, culturally signifying virility and therefore contrary to the conceptions of female propriety (S.K. Cahn 2014: 263).

However the most harrowing comorbidity is that between BPD and post-traumatic stress disorder (PTSD), in particular the experience of sexual assault. In comparison with other psychiatric disorders BPD was the diagnosis most frequently associated with sexual abuse (B. Bandelow et al. 2005: 170). This is a near-universal finding buried in literature about BPD and replicated in multiple studies (P. Bjorklund 2009: 8). Furthermore the interview method conducted in these studies may have even led to a possible underreporting of sexual abuse due to the repression of traumatic events (B. Bandelow et al. 2005: 177). The high rates of sexual traumatisation in patients have led to discussion of whether BPD represents a trauma-spectrum disorder (B. Bandelow et al. 2005: 176). However, trauma as an aetiological antecedent of BPD is entirely omitted from the DSM and all its reiterations despite the empirical consistency. The “borderline” woman acts as a disembodied epithet, objectivating the troubling aspects of womanhood as a pathological illness, rather than an acute reading to the madness of a society where sexual violence is pervasive (S.K. Cahn 2014: 273). The responsive anger, self-injurious behaviours, and interpersonal lability are villainised as attention-seeking, manipulative, and promiscuous. Similar to the 20th century Victorian malady of hysteria, borderline personality disorder is rooted in the moral vision of the ideal woman as silent, impervious, and willing (S.K. Cahn 2014: 259).

Thus far, medicalisation as the creation, promotion, and implementation of medical categories has partially explained the way mental illness is socially constructed (P. Conrad 2013: 200). The classification of illnesses involves the interpretation of medical findings, circumscribed by normative definitions of health and illness (P. Conrad 2013: 202). Additionally, one’s social ecology will inform the development and expression of mental disorders. However, biological reasoning as an outcome of medicalisation depoliticises the condition as an individual pathology rather than an embodiment of structural arrangements (J. Busfield 2017).

Medicalisation is therefore understood as a pejorative within sociological literature (P. Conrad 2013: 205). However, it can also act as an engine to legitimate mental illnesses. The role of the physician is to inherently intervene and alleviate suffering related to the body and psyche (P. Conrad 2013: 205). Psychiatry, and medicine more broadly, has become a repository of truth as an institution of expert knowledge (J. Busfield 2017: 759). The diagnostic mandates and clinical interpretations of a physician is seen as a moral and political arbiter – disinterested and objective (J. Busfifeld 2017: 759). According to Talcott Parson’s structural-functionalist theory, a diagnosis positively and medically sanctions patients under the “sick role” that entails certain responsibilities and exemptions. Being unable to fulfil the expectations and functions of contemporary civilisation, they’re afforded a different, albeit temporary, set of rights and duties (T. Parsons 1991). That is: the right to be exempt from normal social roles; the right not to be held responsible for the condition; a duty to seek treatment; a duty to co-operate with technically competent help. It frames deviance as amoral, unwilling, and organic (S.H. Sulzer 2015: 8). Conversely, the conception of personality disorders in the beginning of the 19th century was initially described as moral insanity (N. Manning 2000: 622). It implied a wilful deviance rather than a legitimate illness that’d warrant the “sick role” (S.H. Sulzer 2015: 2). This illuminates the way medicalisation can function in a positive way with pertinence to personality disorders.

However, there has been a de facto demedicalisation of borderline personality disorder (S.H. Sulzer 2015: 1). It is framed as an ontological deficit and self-inflicted deviance, contrary to the “sick role” (O. Bonnington & D. Rose 2014: 12). Not only does the de facto demedicalisation enacted by clinicians exacerbate the mortality of BPD by routing patients out of treatment, but acts to deny the existence of the disorder and invalidate its traumatic aetiology – in particular sexual assault. This is a harrowing parallel to the way survivors are often treated.

The psy- professions regard BPD as one of the most intractable, mirrored in the ubiquitous “difficult patient” label (S.K. Cahn 2014: 263). Psychiatrists mentioned the diagnosis of BPD four times more often than any other diagnosis when asked about the characteristics of difficult patients (O. Bonnington & D. Rose 2014: 1). In the same study, “manipulative” was the most-commonly used adjective by health providers to describe patients with BPD (S.H. Sulzer 2015: 10). The DSM’s criterion of BPD is clinically reinterpreted as the following: manipulative; aggressive; attention seeking; uncooperative, surmised as difficult (O. Bonnington & D. Rose 2014: 12). This informed why health providers refused care as they believed patients with BPD feigned sickness to get attention (S.H. Sulzer 2015: 10). Thus, patients with BPD are displaced from the “sick role”, indicted under a logic of culpability where they are responsible for their own illness (S.H Sulzer 2015: 4). Literature on eating disorders found that patients diagnosed with BPD were denied care in eating disorder clinics. After being marginally, physically stabilised they would be removed from the ward in favour of caring for other patients who were “legitimately” sick. Although these patients met the clinical markers for anorexia, their disordered eating was labelled as pretence and an attempt to gain attention (S.H. Sulzer 2015: 11).

It creates a narrative of a contested illness that is more a moral transgression, and operates as a rhetorical justification to routinely deny patients care as documented in the 2010 Report to Congress on Borderline Personality Disorder (S.H. Sulzer 2015: 11). An unfortunate corollary, while BPD has proven to be as manageable as Major Depressive Disorder, patients with BPD remains the highest suicidal patient group (S.H. Sulzer 2015: 2). 3- 10 per cent of BPD patients die from suicide, and one study found more than 70 per cent have attempted either suicide or parasuicide (S.H. Sulzer 2015: 3). Even though there is proven efficacy of BPD-oriented therapies such as DBT, and various psychiatric drugs that alleviate emotional lability, patients are either seen as resistant or that there is no legitimate disorder to treat. This creates a discourse of untreatability.

Additionally, research found that clinicians conceptualise these suicidal and self-injurious behaviours as a patient’s clinical manipulation rather than temporary coping methods for intense emotional pain – as described among BPD patients themselves (S.H. Sulzer 2015: 11). It seems that the stigma surrounding BPD is largely maintained in the healthcare system where professional opinion is socially organised as objective forms of knowledge. Thus, many patients diagnosed with BPD are then powerless in resisting exclusion from treatment (S.H. Sulzer 2015: 9). BPD carries the historical vestiges of personality disorders as moral insanity, from its original conception in the 19th century to the early 20th century revision of hysteria that disguised itself under a biomedical paradigm, but was the embodiment of the patriarchy values and attitudes necessary for the maintenance of Western, neoliberal, civilisation (P. Bjorklund 2009: 17). The restitution of the “sick role” requires the medical recognition of BPD, returning patients under the purview of treatment and compassion. Not only will this address the mortality of BPD, but validate the expressions of BPD as a response to the crippling oppression of modern patriarchy (P. Bjorklund 2009:6).

In summary, medicalisation is the distinction between health and illness. It is a negotiated process rather than an absolute category, contingent on prevailing systems of truth (S.H. Sulzer 2015: 6). This informs the way mental health disorders are socially shaped, and therefore functions as a tool of social control. The DSM as a nosological tool, classifies deviance and mandates it under medical purview. As an institution of expert knowledge, it naturalises and is informed by dominant paradigms constitutive of Western, neoliberal patriarchy. BPD is a gendered disorder with women outnumbering men 3:1. Its symptoms are the embodiment of behaviours that are contrary to ideal femininity, contextualised in a period of feminist activism concerning the sexual liberation and violence of women. It’s categorical deviance functions to shroud the troubling aspects of womanhood that reveal a structurally oppressive society. Conversely, medicalisation can also act to legitimate the self-destructive feelings of patients which lie in a spectrum of responses to trauma, particularly sexual assault. By acknowledging the way medical conduct is influenced by social hegemony and the cultural history it carries as a means of marginalisation, health practices can be reoriented to prevent, ameliorate, and heal severe emotional pain (S. Cahn 2014: 275).