Busting the Stigma: Understanding High-Functioning Borderline Personality Disorder (BPD)

The term 'high-functioning' is often used to describe individuals with Borderline Personality Disorder (BPD) who appear to be functioning well in society. This misconception can lead to significant misunderstandings and further stigmatization.

Why Do People With BPD Seem High-Functioning?

High-functioning refers to the ability to perform well in certain domains, such as academic or professional settings. However, this doesn't mean that individuals with BPD, regardless of their high-functioning status, are not struggling deeply behind closed doors. Their ability to function well in public is a symptom of their adaptation to society, not a sign of their mental health.

Individuals with BPD often have poor insight into their own behavior and may blame others for their issues, stating, 'they are not like that.' This lack of self-awareness can make it difficult for them to acknowledge their problems and seek help. Furthermore, they may 'mirror' their perceived societal expectations, acting outwardly well-behaved to avoid scrutiny or judgment.

Why the Stigma Persists

The stigma around BPD often comes from the belief that all individuals with BPD act out, disrupt social norms, and exhibit problematic behavior in both personal and professional settings. However, many individuals with BPD are high-functioning, which can mask the real issues they are dealing with.

It's important to recognize that BPD is not a monolithic condition. Different individuals experience it in different ways. This variability can lead to misdiagnosis and misattribution of symptoms, further perpetuating the stigma. For instance, someone with BPD may have different expressions of the disorder, such as internalizing rather than externalizing symptoms, or may exhibit low anger and high self-control.

The DSM and Co-morbidity

The Diagnostic and Statistical Manual of Mental Disorders (DSM) groups comorbid conditions with BPD, leading to the inclusion of Narcissistic Personality Disorder (NPD) in some cases. This can exacerbate the stigma by creating extremely toxic personality types. These individuals, often called covert narcissists, may be a significant source of emotional trauma in society.

Revisiting the Stigma and Diagnosis

Borderline Personality Disorder is a complex condition that cannot be generalized based on a superficial observation or diagnosis. The presence of mature defenses, rather than the absence of immature ones, is a more accurate indicator of a healthier personality organization than the mere presence of BPD traits.

The underlying psychodynamic factors involved in BPD are present in many individuals who never go on to be diagnosed with it. For example, most people can use immature defense mechanisms in certain situations, and may temporarily regress to the paranoid-schizoid position. This highlights that BPD is not so categorical, but rather a developmental issue.

The key distinction lies in developmental arrest. Individuals who develop non-borderline personalities have resolved certain early-life experiences involving part-object relations, while those with BPD do not, or do so to a lesser extent. This is a core concept that Nancy McWilliams discusses in her book Psychoanalytic Diagnosis.

The Need for Precise Diagnosis and Individualized Attention

To truly understand and address BPD, it's important to recognize the spectrum of severity and the individualized nature of the condition. BPD subtypes, as detailed in the International Classification of Diseases (ICD-11), provide a more nuanced and accurate picture of the disorder, distinguishing between mild, moderate, and severe cases.

By acknowledging the variability in BPD, we can better support those affected, reduce stigma, and promote effective treatment. It's crucial to focus on the unique needs of each individual with BPD, rather than making sweeping generalizations.

Recognizing and addressing the stigma surrounding BPD, especially in high-functioning individuals, is a critical step in improving the lives of those affected. By fostering a more nuanced understanding, we can work towards a society that is more accepting and supportive of mental health issues.