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BPD and Misdiagnosis

Why is BPD Misdiagnosed So Often?

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Updated October 05, 2010

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

Many people with borderline personality disorder (BPD) have had the experience of misdiagnosis. But why is BPD so much more difficult to diagnose than other psychiatric problems? And what can you do to get an accurate diagnosis?

How Often is BPD Misdiagnosed?

Many people with BPD have stories of misdiagnosis, but how often does it really happen? Unfortunately, there is very little research to draw from, but at least one study suggests that BPD does get misdiagnosed at fairly high rates. A study by researchers at the University of North Texas and Brown University found that nearly 40% of people with BPD in the study sample had previously received a misdiagnosis of bipolar disorder.

There have also been reports of people with BPD being misdiagnosed with psychotic disorders and Asperger's disorder (a type of developmental disorder on the autism spectrum), although there is no research exploring cases of this nature. But, more often, people with BPD report that they received a diagnosis of a mood or anxiety disorder long before their borderline symptoms were recognized. This is not really misdiagnosis so much as "missed diagnosis." Clinicians tend to miss the BPD symptoms at the outset of treatment, so they correctly diagnose other psychiatric problems but fail to catch the BPD diagnosis.

Why is BPD so Difficult to Diagnose?

Why might a BPD diagnosis be missed? There are likely a few different factors at play. First, BPD symptoms are often not evident at the outset of a therapeutic relationship. Many people with BPD do not really "show" their symptoms in more superficial relationships (such as with acquaintances), or in the early stages of relationships.

As a result, a clinician may miss the diagnosis because in the context of therapy the symptoms do not appear. To be clear, it is not that the person with BPD is intentionally hiding their symptoms, but rather that the interpersonal symptoms of BPD really only become evident in the context of close relationships (i.e., the relationships that the person with BPD has more investment in and is more afraid of losing).

To compound this problem, people with BPD may drop out of treatment at relatively high rates. So, if the person with BPD is not showing symptoms early in the therapy, and is also not staying in therapy for long, they may see a string of providers who never get a glimpse of the symptoms.

Another problem may be in the diagnostic criteria for BPD. Many experts believe that the criteria we use to diagnose BPD are too vague and overlapping with other disorders. They argue that BPD has a very high rate of comorbidity (i.e., co-occurrence with other disorders) because our current way to diagnose BPD is not precise enough. Problems with the precision and clarity of the criteria could also lead to misdiagnosis.

Getting an Accurate Diagnosis

If you think you or a loved one might have BPD and you want to get an accurate diagnosis, where should you turn? While it is not always possible to diagnose BPD accurately every time, clinicians who have extensive training in assessing and treating the disorder are much more likely to diagnose you correctly.

If it's hard for the experts to get an accurate diagnosis; trying to self-diagnose is probably not a good idea, particularly given the severity of BPD symptoms. You should certainly learn about your conditions, including personality disorders, but your self-diagnoses should be confirmed or disconfirmed in the context of a therapeutic relationship.

Your best bet is to find a BPD expert and ask for an evaluation. To find a BPD expert clinician, see "Find a BPD Therapist."

Sources:

Ruggero CJ, Zimmerman M, Chelminski I, Young D. "Borderline Personality Disorder and the Misdiagnosis of Bipolar Disorder." Journal of Psychiatric Research, 44(6):405-408, 2010.

Zanarini MC, Frankenburg FR, Dubo ED, Sickel AE, Trikha A, Levin A, Reynolds V. “Axis I Comorbidity of Borderline Personality Disorder.” American Journal of Psychiatry;155(12):1733-1739, 1998.

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