IDoNotExist,

I suggest that the current conception of BPD as a medical diagnosis is fundamentally flawed. Borderline conditions are real, when they are considered as a cluster of complex emotional and relational problems that exist on a continuum or spectrum of severity. However, it does not make sense to create a medical "diagnosis" for borderline conditions based on 9 specific symptoms that must be assessed based on the subjective judgment of an outside observer (the psychiatrist). This is not meant to invalidate anyone - instead, it is saying that we have not developed accurate ways to measure exactly at what point someone has a strong enough version of a certain observable trait to "cross the border" and receive a BPD diagnosis, or not.

There are many professional therapists who support this viewpoints. If you Amazon the books of Thomas Szasz, Peter Breggin, Robert Whitaker, Paula Caplan, Stuart Kirk, and Allen Frances you can get an idea of some of the counter-DSM viewpoints out there. Allen Frances was former chairperson of the DSM task force, and has now turned against his former colleagues to critique the diagnoses based on the DSM.

In that way I agree with you that BPD is somewhat of a wastebasket diagnosis, although paradoxically it can still be useful to think in terms of it sometimes. Rather than the DSM model, IMO the more useful model is a psychodynamic one, which "diagnoses" it based on the degree of splitting and associated defenses a person has. If they have a predominance of all-bad splitting (i.e. their negative images of themselves and others are stronger than their split-off positive images, or memories, of themselves and others) then they can be considered as borderline. Although this approach could also be criticized as being subjective and non-scientific (and those criticisms would be correct), for me it is more useful because it looks underneath the constantly shifting symptoms that are part of BPD to identify the "engine" of the primitive defenses, and the historical lack of positive relational experience, that are driving it.

I recently read in a John Gunderson article that 80% of people diagnosed with BPD are on three psychiatric medications or more, and that for many of those, medication is all they are getting on a regular basis. This was a stunning fact that really hit home how poorly we are managing borderline conditions in the United States. It is truly a tragedy that many millions of people are not getting the intensive social support and/or therapy they truly need to recover from borderline conditions. However, it is not surprising, given that many psychiatrists have realized that they can make more money by prescribing pills that control symptoms (and seeing patients occasionally for brief periods mainly to manage meds) rather than working intensively with patients in long-term therapy (which makes them less money per patient). Psychiatrists and drug companies therefore profit, even when it gives borderline patients less of a chance to recover.

Most borderlines who have recovered to become non-borderline have done so through some combination of intensive long-term psychotherapy, long-term group therapy, and strong community and family/friend support. Medications can help with symptoms but do not cure. However, borderline conditions can be "cured" through interpersonal support, even though cured is not really the right word. Developing a healthy personality, recovering meaningfully and deeply, or becoming mostly symptom-free would be better terms.

I feel that the situation with BPD as a diagnosis is getting worse. This is especially true because university lab researchers, many of whom have never even worked with real-life borderlines, are now using the faulty DSM conception of BPD as a diagnosis to try to identify the genetic basis of BPD. In this, they are fundamentally mistaken, since it is not possible to determine what percentage of BPD is genetic for several reasons. One reason is that BPD as a medical diagnosis is faulty and cannot be reliably assessed, thus skewing results. Another reason is that twin studies are currently under siege and have had many of their basic assumptions challenged by the emerging field of epigenetics, as well as by common sense criticism. Jay Joseph and Evan Charney write well about this.

I realize that my view is incompatible with mainstream psychiatry and might be unsettling to some. However, I would urge people to consider the degree to which psychiatrists, hospitals, and drug companies profit from medicalizing BPD, given the amount of money it allows them to make from prescribing pills and short-term treatments rather than providing long-term therapy and support. Providing long-term intensive therapy is unfortunately not as lucrative, and it requires that people with BPD be viewed as unique individuals with a history contributing to their current condition, something that takes much more effort than prescribing a pill.

If we are not satisfied with the current system of understanding and treating BPD, and find we are not recovering as fast as we would want, then perhaps there is something wrong with how the current system understands and treats BPD. That does not mean we are not responsible for getting better, or that recovery should be done for us. Rather, it means that understanding BPD and recovering from it are complex challenges and that the way society deals with the condition is important. I hope that idea is useful to some on here. Thank you for listening to my rant