Diagnosing Borderline Personality Disorder and Self-Harm

Available with English captions and subtitles in Spanish.

A conversation with Andrea Gold, PhD, Ana Rodriguez-Villa, MD, MBA, and George W. Smith, LICSW, on the many facets of diagnosing BPD and self-harm.

Why an Accurate BPD Diagnosis Matters

Diagnosing borderline personality disorder (BPD) is often as complex as the condition itself. Symptoms such as self-harm can overlap with or be related to other mental health challenges. Unfortunately, misdiagnoses are common.

In this session, the experts explore what it takes to accurately identify BPD and similar disorders, from recognizing key signs and symptoms to asking questions that can provide critical context and understanding.

Watch now to learn more about:

  • How clinicians make a BPD diagnosis
  • Who can treat BPD
  • How stigma can be overcome in diagnosis and treatment

In this talk, Gold, Rodriguez-Villa, and Smith explain how conceptualizing borderline personality disorder is the first step in making a diagnosis.

Gold explains, “I think of borderline personality disorder as a disorder of instability of emotional experience within relationships and within oneself.”

The experts outline and discuss the nine factors that can make up a BPD diagnosis. They remind us that a person needs to meet only five of these nine factors, which can be part of what makes it difficult to correctly pinpoint BPD in an individual. They also emphasize that, with training, a generalist can make a BPD diagnosis.

In addressing the role of self-harm in BPD, Gold says, “We want to ask the question, ‘WTF: What’s the function?’” She explains how self-harm can serve as a way to regulate emotions, and how it can also be a form of communication when people have a hard time receiving validation or attention.

The experts each highlight the importance of considering co-occurring conditions, such as substance use disorders, PTSD, ADHD, and autism. They point out the importance of differentiating between BPD and other conditions, such as bipolar disorder, that can have similar presentations.

BPD can affect the entire family, and it’s important for family members to receive education and be involved in treatment. According to Smith, when he works with families, he tells them, “Let’s find a way to talk about what this has been like for everyone.”

He adds that when he starts working with a patient, he has a meeting with the individual and their parents. “I’ll always ask the patient how they understand the nature of their problems and what they’d want to work on, and then I ask the parents the same thing,” he says.

In addition to addressing stigma among people with BPD, the experts address the reluctance of clinicians to share a diagnosis of BPD with patients. They stress that such discomfort within the profession only heightens stigma and prevents patients from receiving the care they need.

Rodriguez-Villa shares that when she hears such reluctance from colleagues, it often comes from worry about a patient’s reaction to a BPD diagnosis. She states that in her experience in giving the diagnosis, patients’ responses are overwhelmingly positive.

“[A BPD diagnosis] is validating, it is helpful, and that is the large predominance of experience: When [patients] get a diagnosis like this, it can help.”

Audience Questions

  • What characteristics are most associated with borderline personality disorder (BPD)?
  • Can you name and define some key diagnostic terms related to BPD?
  • What can a diagnostic process look like? What are the criteria?
  • How does self-harm fit into the BPD diagnosis process? Can it occur independently of BPD?
  • When we talk about self-harm, are we also talking about substance use as a form of self-harm?
  • Are there individuals who will meet five of the needed DSM criteria for BPD but who live with a different disorder?
  • What should we know in terms of dysregulations as they pertain to BPD?
  • Is BPD especially complicated to diagnose?
  • Can someone under 18 be diagnosed with BPD? Does stigma factor in?
  • What are some basic signs and symptoms that loved ones might watch for at a subclinical level?
  • Is it true that individuals can age out of BPD? If so, at what age should we consider that something that may look like BPD actually is not?
  • What should we know about co-occurring conditions and how they factor into the diagnostics process?
  • What should clinicians look out for when differentiating between BPD and autism spectrum disorder?
  • Is it true that a personality disorder is not sufficient for insurance reimbursement?
  • Because BPD can be misdiagnosed, how do previous diagnoses get changed or removed?
  • Do you ever work with family members or loved ones during the diagnostics period?
  • Do you have any suggestions on how clinicians can work with colleagues who are still hesitant to diagnose BPD under 18?
  • What are some of the common conditions that are mistaken for BPD?
  • Is it true that males are typically diagnosed with antisocial personality disorder in place of BPD?
  • How is the presentation of impulsivity for someone with ADHD different from someone with BPD?
  • At what point might a clinician without BPD expertise want to refer out to a BPD specialist to help diagnose a patient?
  • How much overlap is there between OCD and BPD? Is it usually a one or the other diagnosis or can they co-occur?
  • Can you elaborate on the concept of “holding”?
  • How do you use transference and countertransference to identify BPD?
  • Is there a broader discussion going on in the field about stigma around a BPD diagnosis?
  • Is “quiet BPD” something you’ve seen?
  • What is narcissistic personality disorder (NPD)?
  • Can you give us a hypothetical example of real-world scenarios where BPD diagnostics are challenging?
  • Is there a minimum number of sessions that a clinician should consider before providing a BPD diagnosis?
  • How do you deal with a patient that comes in who has been misdiagnosed? How can you assuage concerns and skepticism?
  • How should clinicians factor cultural considerations into BPD diagnostics?
  • Can you speak to complex PTSD and its relation to BPD?
  • Have people who are diagnosed with BPD later in life been living with it for a long time? Or, is it possible for later life events to bring about BPD symptoms?
  • Can you share a key takeaway when it comes to diagnosing BPD?

The information discussed is intended to be educational and should not be used as a substitute for guidance provided by your health care provider. Please consult with your treatment team before making any changes to your care plan.

Helpful Links

You may also find this information useful:

Andrea Gold, PhD

Andrea Gold, PhD, is a clinical assistant professor in the Department of Psychiatry & Human Behavior at the Warren Alpert Medical School of Brown University and a staff psychologist at the Pediatric Anxiety Research Center (PARC) at Bradley Hospital.

Ana Rodriguez-Villa, MD, MBA

Ana Rodriguez-Villa, MD, MBA, is the associate medical director for McLean’s Clinical Evaluation Center and a staff psychiatrist at the Gunderson Residence—an intensive, specialized residential program for women living with personality disorders.

George W. Smith, LICSW

George W. Smith, LICSW, is the director of outpatient group therapy services for McLean’s Adult Outpatient Services and clinic director of the Borderline Personality Disorder Outpatient Program.

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