What does the Court of Protection need to know about “borderline personality disorder” or “emotionally unstable personality disorder”: An update 

By Keir Harding, 19 June 2024

This is an update of a blog I wrote in November 2020.  A few things have changed since then so while the bulk of the text is still intact, I’ve added a couple of developments and included what changes we might expect from the International Classification of Diseases [ICD]-11, the diagnostic manual in the UK that superseded the ICD-10 in January 2022.  
 
“Borderline Personality Disorder” and “Emotionally Unstable Personality Disorder” are interchangeable terms for a mental health diagnosis typically given to someone who has difficulty managing their emotions, copes in ways that can cause problems for them, and has difficulties with relationships. In theory, it is a diagnosis given by a qualified mental health professional. It is classed as a mental disorder which means that a person with the diagnosis could be detained under the Mental Health Act  (1983). There is a NHS webpage about it here, and a Mind page here.  

For the diagnosis to be given appropriately according to the psychiatric criteria,  people’s symptoms should meet the 3 Ps. Their difficulties should be:  
Persistent – Not waxing and waning, not relapsing and remitting but relatively constant.  
Pervasive – In every area of life. They shouldn’t function brilliantly in one area and not in another.  
Problematic – It has to cause distress to them.  
 
All of the above is theory. But these diagnoses are in reality very contested, and in my experience and the experience of many people who have these diagnoses, the diagnosis can be arrived at after a very brief consultation and without a thorough assessment. I argue that this means, in respect of the Court of Protection, that in proceedings where P has one of these diagnoses, it is important to establish how the diagnosis has been arrived at – and to confirm that it is the result of a rigorous assessment, rather than the ‘gut feeling’ of a clinician. The Royal College of Psychiatrists recommends that“diagnosis should only be made by those qualified to make it and only following a thorough assessment”.  That this has to be stated possibly reflects how little thought can go into the label being applied.  
 
A Contested Diagnosis 
 
There are 10 different types of personality disorder listed in the Diagnostic and Statistical Manual of Mental Disorders (the ‘DSM 5’) – which is published by the American Psychiatric Association, and used to diagnose mental disabilities in the United States and some other countries. These are: paranoid, schizoid, schizotypal, antisocial, borderline, narcissistic, histrionic, avoidant, obsessive-compulsive, and dependent. It’s also possible to be diagnosed with a “mixed personality disorder” or with a personality disorder that doesn’t quite meet the criteria for any of these diagnostic categories (“a personality disorder not otherwise specified”). 
 
I’ve worked in a variety of mental health settings for the past 20 years and I have met fewer than 10 people with a personality disorder diagnosis that isn’t  either “borderline” or “antisocial”.  So, while in theory there are 10 types of personality disorder, only 2 of them seem to be regularly diagnosed.    
 
In my experience, if you are a woman who self-harms, you will get a Borderline Personality Disorder (BPD) diagnosis regardless of whatever else is going on.  Something in this system is definitely wrong.  
 
The World Health Oorganisation [WHO] attempted to do something different when they revised the ICD-10.  At first, they got rid of all of the different types of ‘personality disorder’ diagnoses meaning that people would simply be diagnosed with “Personality disorder” which could be graded as mild, moderate or severe.  The former Chair of the WHO personality disorder group described Borderline Personality Disorder as  “a spurious condition unsupported by science that should be abandoned” and it was abandoned until intense lobbying resulted in BPD making it into the ICD-11 as a descriptor.  Now, your diagnosis can be “Personality Disorder: *rating of severity: Borderline Pattern”.  In theory, borderline pattern is diagnosed if someone meets 5 of the 9 criteria for BPD.  It has yet to be shown whether this change will make a huge difference but some have suggested that by including a BPD option, clinicians will default to what they have always done.  This change means that EUPD should fade out of being used as a diagnosis as more trusts move to using the ICD-11 
 
The ICD-11 does include the diagnosis of complex PTSD, which may well describe the repeated damaging life experiences so common in those given a Borderline Personality Disorder diagnosis. It is certainly indisputable that those who recieve a BPD diagnosis are predominantly those who have lived through trauma and abuse.  Some studies suggest 80% of those with the diagnosis have lived through such experiences and it is recognised as the diagnosis most associated with childhood abuse.  A CPTSD may well help everyone looking at the difficulties someone experiences as natural consequences of what they have lived through as opposed to some sort of disorder or defect that lies within them.  
 
Table BPD criteria 
 
1. Chronic feelings of emptiness 

2. Emotional instability in reaction to day-to-day events (e.g., intense episodic sadness, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) 

3. Frantic efforts to avoid real or imagined abandonment 

4. Identity disturbance with markedly or persistently unstable self-image or sense of self 

5. Impulsive behavior in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) 

6. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 

7. A pattern of unstable and intense interpersonal relationships characterized by extremes between idealizationand devaluation (also known as “splitting“) 

8. Recurrent suicidal behavior, gestures, threats, or self-harming behavior 

9. Transient, stress-related paranoid ideation or severe dissociative symptoms¹ 
 
Research suggests that if you can be diagnosed with one personality disorder, it’s highly likely you’ll meet the criteria for another two.  So that’s 3 personality disorders in all.  In a system that aims to put people into a neat tidy box so that we know a care pathway, it becomes messy because they’re actually in 3 boxes (and they probably display some traits from a few of the other diagnostic categories too).   
 
To be given the diagnosis you need to match 5 of the 9 relevant criteria.  Let’s say my friend Ian and I are on the same hospital ward.  He meets criteria 1-5 and I meet criteria 5-9.  So, we have the same diagnosis, the same treatment plan, and yet we share only one characteristic.    
 
Borderline Personality Disorder could certainly be argued to be the most stigmatised diagnosis out there. As long ago as 1988, an article in the British Journal of Psychiatry (“Personality Disorder: The patients psychiatrists dislike”) reported research showing that psychiatrists treated patients with this diagnosis as more difficult and less deserving of care compared with other patients.  The authors wrote: “The PD cases [sic] were regarded as manipulative, attention-seeking, annoying, and in control of their suicidal urges and debts. PD therefore appears to be an enduring pejorative judgement rather than a clinical diagnosis. It is proposed that the concept be abandoned.” 
 
Dialectical Behaviour Therapy is the most researched therapy for Borderline Personality Disorder.  Its creator, Marsha Linehan (quoted here: “Why you don’t want a diagnosis of Borderline Personality disorder”), advises people who are given the diagnosis “if you end up in the Emergency Room for a medical disorder for gods sakes do not tell them you meet criteria for Borderline Personality Disorder.  Do not tell anybody.  You’ll be treated differently and many, many mental health practitioners won’t see someone who meets criteria for Borderline Personality Disorder”.
 
The question can be asked “Are people with borderline personality disorder the patients psychiatrists dislike, or are the patients psychiatrists dislike told they have BPD?”  The example below from Aaron Beck, the creator of CBT suggests the latter: 
 
A story of two mental health staff talking goes like this:  
“I’m having problems with my patient with Personality Disorder”  
“How do you know they have personality disorder?”  
“Because I’m having problems with them.”  
 
This is why I feel it’s very important that when the court accepts that someone has the diagnosis of BPD they ensure that this is based on a thorough psychiatric examination from an expert in the field, using a trusted rating scale and finding the person to have met the diagnostic criteria.  A person does not “have BPD” simply because their care team find them challenging.   I frequently meet people with this diagnosis who do not meet the criteria but have this label written all over their notes.   
 
Even when people are shown to have met the criteria, the court should be aware of the subjective nature of assessment for this diagnosis.  Those deciding that anger is “inappropriate” (Criterion 8) or that attempts to avoid abandonment are “frantic” (Criterion 1) may well have difficulty appreciating the unique set of circumstances those they assess are living through.  
 
There is a language around people with this diagnosis that invites people to treat them badly or even cruelly. They are often described as attention seeking, manipulative and in many ways not truly deserving of care. They take up places in the healthcare system that could be used for people who are “really ill”. They are ascribed mythical powers to be able to tear apart previously high functioning teams and, despite a suicide rate of 1 in 10, are rarely taken seriously when describing being suicidal. It is very hard to be helpful to people when you label them as disordered and see them as holding all the characteristics above. This isn’t something society would expect caring people to do. 
 
There are a range of therapies with an evidence based for helping those with this diagnosis, but these treatments are not always accessible.  While DBT is the only one specifically mentioned in the NICE guidelines (specifically for women where self harm is a significant issue), the evidence base is similar for Metallisation Based Therapy (MBT), Cognitive Analytic Therapy (CAT) and many others.  It is always worth checking what help has been offered and whether that help has an evidence based for the problems being described.   
 
Perhaps a more useful way of thinking about this is through the lens of trauma.  I’ve very rarely worked with anyone where the difficulties they have now don’t make sense in terms of previous experiences of neglect, abandonment and abuse. If we can remember what has happened to people, we tend to be empathic. When we label that person as disordered, we tend to locate the problems in them rather than the people or circumstances that hurt them, or the circumstances of their trauma. I would bet money that this label is disproportionately applied to the girls who survived the child sexual abuse scandal in Rotherham – but the people we sympathise with now will be the people who are blamed for their problems in the future.  Again, it’s worth checking if any evidence-based help around trauma has been offered.  
 
Jay Watts writes of testimonial injustice once this label is applied. The words of those given the diagnosis are seen as meaningless because an expression of pain is viewed as just seeking attention, and a legitimate complaint is ‘typical PD’. “Inappropriate anger” is one of the criteria for BPD and what greater power imbalance can there be for someone whose reactions to injustice are labelled by others as “inappropriate”? 
 
Many would argue the diagnosis can be useful and I sometimes find it helpful for those I work with, if only because it comes with ‘NICE’ (National Institute for Health and Care Excellence) guidelines (see here and here) that recommend specific ways of helping people with this diagnosis. I help a lot of people leave compulsory treatment because the care they are receiving bears no relation to what is recommended in the guidelines.  In the face of risk, teams move from “being with” people and start “doing to” people.  Collaboration ceases and as people respond badly to the restrictions (whose potential for harm is spelled out in the guidelines), this is only seen as evidence to restrict more.  Recommended therapies are not provided or are provided by those who are untrained – and despite a recommendation not to prescribe medication for BPD, polypharmacy (the prescription of multiple medications to one person daily) is rife.  
 
Another common theme I see in legal reports is for someone’s current presentation to be generalised to their entire life.  It can be forgotten how an inpatient environment is often perceived as harmful and not recommended for people with this diagnosis, with the ‘NICE’ guidelines telling us admission should only be used during a crisis.  When people are compelled to reside in a harmful environment, it would make sense that their behaviour changes substantially.  With that in mind I would always want the court to think about whether behaviour used as evidence for anything in one environment can reliably be applied to different environments where often that behaviour has never occurred. 
 
The Consensus Statement for People with Complex Mental Health Difficulties who are diagnosed with a Personality Disorder was published in 2018. In this statement,   many people with lived experience and some professional bodies including the British Psychological Society stated “We would like to abandon the term ‘personality disorder’ entirely”.  That won’t happen any time soon though and its arguable that the ICD-11 category of “personality difficulties” will open the door for many more people being seen through the lens of personality disorder with the implications already outlined.” This is a scary prospect and while seeing that someone has a diagnosis of BPD will tell you much about their relationship with those who should care about them, it will tell you nothing about the value of their personality.  
 
The ICD-11 allows the diagnosis of children from the age of 14 with personality disorder.  The current RCPsych guidelines state “it is important that the diagnosis is made in this age group”.  Over 1200 mental health professionals signed an open letter calling for children not to be diagnosed until it can be proven that the diagnosis does not harm them in May 2024.   
 
I very much hope that the contested and controversial nature of personality disorder diagnoses that I’ve described here is understood and borne in mind by the Court of Protection whenever it makes decisions concerning people with one of these diagnoses.   
 
Keir Harding is an Occupational Therapist and Dialectical Behavioural Therapist with 20 years’ experience in mental health and an MSc in ‘personality disorder’.  He has been a lead therapist NHS services and is now Clinical Lead for Beam Consultancy.   Keir works closely with people with lived experience to provide training, expertise and therapy to help avoid long term hospitalisation. He serves on the executive board of the British and Irish Group for the Study of Personality Disorder.  He tweets @Keirwales and is Keir Harding on Linkedin, and Keir Harding OT on Facebook.  He co-presents the podcast The Wrong Kind of Mad on the topic of “personality disorder” with Hollie Berrigan. 
 
 Postscript: Keir tried to get out of writing this, hoping that some of those who were critical of him writing the first blog would step up to improve upon it.  In the absence of any other volunteers he revised the original piece and fully appreciates it could be better. Two very readable lived experience pieces describing the impact of being given this label can be read (here) and (here)