Diagnosing BPD

One of the first questions a Non often asks is, "How can I be sure that the person in my life that I think has BPD really does?" This is an important question for most Nons due to the fact that the BP in their life projects their craziness onto the Non. In fact as soon as a Non shares the idea of BPD with their significant other, the diagnosis itself is often projected. "I’m not the one with BPD, but maybe YOU have it?" is a typical BPD response. See "Who is Sick" for more on this idea.

Many of the people on our lists do not have an official diagnosis from a qualified health care professional. They simply observed the behaviors of their significant other, were pointed in the direction of the BPD diagnosis, read it and had the light bulb effect. In order to care for yourself, an official diagnosis is not very important. If they quack like a BP, you can use the resources of BPD411 to improve your life. Learning effective boundaries is useful whether the person in your life that is presenting you challenges has or does not have BPD.

An official diagnosis can be important for legal and other reasons. Unfortunately, this can be VERY difficult. BPD is a very secretive and selective disorder. High functioning BPs present particular difficulties in diagnosis. Many BPs only have the BP behavior in their primary relationships, and can be highly thought of in professional and community circles. My own experience with this was that it was very hard to get court appointed evaluators to acknowledge the dysfunction that they saw. One said to me, "What was in my report was about as clear as it ever gets." The report was very vague, and finally recommended for the BP mother to maintain custody.

If the health care professional giving the diagnosis is the therapist of the suspected BP, then it is even harder to get a specific diagnosis. This is because many therapists believe that in diagnosing a patient with BPD, that they are labeling them and reducing their ultimate ability to achieve some recovery. This makes some sense in that once a BP is labeled as such, they become highly defensive and therapy becomes much more difficult. Eventually, all successful therapy will involve the BP accepting their diagnosis and moving forward, but it takes many months of therapy for the relationship with the therapist to grow to the point that sharing the diagnosis with the person will have any positive effect. Until that time it is highly counter productive.

In addition to the psychological downside of a diagnosis of BPD, there is a financial downside for the therapist. If an official diagnosis of BPD is reached, the therapist may have difficulty collecting money from the insurance company or HMO that is paying for the treatment. Because many insurance companies believe that BPD is either incurable or takes so long to cure as to be actuarially speaking incurable, they won’t pay for treatment. Official diagnosis can be difficult to achieve for this reason from the primary provider of therapeutic health care. This may also account for the DSM-IV’s optimistic outlook on the curability of BPD.

If you need a diagnosis for legal purposes (such as a custody dispute) then you should try and find an evaluator that is NOT the therapist of the BP. Try to find someone who has diagnosed BPD before. Make sure that they have enough time to do the work. Make sure that the evaluator has access to witnesses of the BP’s behavior. BPD cannot be diagnosed in a short amount of time. It cannot be diagnosed without correlating witnesses. Make sure that the evaluator has plenty of time (at least two months) and talks to all the people involved.

To emphasize the importance of moving forward even without a concrete diagnosis, I quote the following dialog from Dr. Leland Heller. You won’t find me quoting Heller often, as he holds out more hope for curing BPD than is justified in my experience. Nevertheless, here is an excerpt of what he had to say about diagnosis:

Q: When a person comes into your office, Dr. Heller, are there any tests you do to determine if the person is BPD?

Dr Heller: I go over the DSM criteria. There are no blood tests, physical examination findings, or imaging studies that can give the information.

...

Dr Heller: This is something I emphasize - no one "is" BPD, they have BPD. No more than someone is a bad gallbladder. There are neurological soft signs. There can be short term memory impairment, visual findings - but these are specialized and are not specific to the BPD. In other words, it won’t make a difference. The BPD is a potentially life destroying illness that must be treated even without "proof." This is no different than someone going to the emergency room with crushing chest pain, shortness of breath, left arm numb, breaking out in a sweat and vomiting. It’s presumed to be a heart attack first, and we go from there.

And for Nons, you don’t need proof to implement proper boundaries, get safe and take care of your own needs.

BPD411 Home - Services - Resources - Partners - Contact Us - Mailing List

Disclaimer: The information on this site (http://www.bpd411.org) is based on personal experiences of the authors and members of our e-mail mailing list. It is NOT meant to replace professional advice or take the place of counseling, therapy or additional personal research.