Ragalika Veeranala
According to the Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V), “a personality disorder is one in which an individual exhibits behaviour that is not normative of their culture, emerges during adolescence, and is enduring and distressing” (APA, 2013). They can roughly be divided into twelve categories; one of which is Borderline Personality Disorder (BPD). It is characterised as a “prevalent pattern of lack of stability in interpersonal relationships, noted impulsive behaviour, identity disruption, repeated self-harm/suicidal behaviour/ideation, emotional instability, and desperate efforts to evade abandonment” (APA, 2013). It is a serious mental disorder and poses great risk to the patients in terms of mortality and morbidity (Crowell et al., 2009). It is troubling to notice that those belonging to sexual minorities i.e., individuals who are attracted to the same sex and/or identify themselves as gay, lesbian or no particular orientation (Cohler & Hammock, 2007), are overrepresented in the prevalence rates of BPD (Rodriguez-Seijas et al., 2020; Reuter et al., 2015; Grant et al., 2011). This piece seeks to explore whether such individuals are predisposed to developing BPD by virtue of their identity or if there is something else at play that causes this gross overrepresentation.
Rodriguez-Seijas et al., notes that a significant overlap has been observed between the diagnostic criteria of BPD and the way individuals belonging to sexual minorities tend to behave (2020). Like those with BPD, they tend to be sensitive to rejection, thus anticipating, apprehending and over-reacting to it in fear of abandonment (Hatzenbuehler, 2009; Pachankis et al., 2008). This negatively impacts their interpersonal relationships, mirroring the BPD criterion of difficulties noted in the same. Research further highlights that sexual minority individuals are likely to engage in impulsive behaviour relating to substance-abuse and sex (Blum et al., 2020; Parent et al., 2019). Due to this, they readily meet the criterion of “displayed impulsivity.” Moreover, they also exhibit high levels of suicidal ideation as well as non-suicidal self injury (De Graaf et al., 2006; Muehlenkamp et al., 2015; Barnett et al., 2019) thus fulfilling the criterion of frequent suicidal actions. Furthermore, they experience a lot of confusion regarding their sexual orientation and identity (Morgan et al., 2013), mostly because it deviates from the heteronormative culture that they’ve been brought up in and has the possibility of inducing dismissiveness from friends and family (Everett et al., 2015). Since distress or confusion regarding identity is also a criterion for BPD, they satisfy this as well. Overall, sexual minority individuals seem to neatly fit into the categorization of BPD.
The question worth asking is whether this overlap means that individuals with non-heterosexual orientations are generally more vulnerable to developing BPD in their adolescence than heterosexual individuals? Empirical evidence points towards the fact that due to their stigmatized identity, sexual minorities are at a greater risk for developing a range of mental health issues than their heterosexual counterparts. (Meyer, 2003; Cochran et al., 2003; Cochran & Mays, 2000; Sandfort et al., 2001) However, a causal relationship between sexual orientation and the manifestation of borderline characteristics has not yet been found (Reuter et al., 2015; Rodriguez-Seijas et al., 2020).
It has been noticed that clinicians are more likely to provide a diagnosis of BPD after an individual reveals that they belong from a sexual minority (Eubanks-Carter & Goldfried, 2006). BPD is significantly correlated with PTSD, CPTSD, and other kinds of pyschopathology (Harned et al., 2010 ; Barnow et al., 2005). Even after controlling for these comorbid conditions, a sexual minority individual posed a higher possibility of being diagnosed or labelled as ‘Borderline’ (Rodriguez-Seijas et al., 2020). Why might this be the case? There are three potential explanations to this, which can collectively help us see the bigger picture underlying this gross overrepresentation.
The stressors faced by the individuals from the sexual minority are different and significantly more extreme than their heterosexual counterparts, when it comes to many experiences. Meyer describes this as minority stress (2003). The distal and proximal stressors include difficult extrinsic life events, anticipation and caution for the same, and internal attribution of antipathetic attitudes of friends and family (Hatzenbuehler et al., 2008). The maladaptive personality traits that stem from these, can be viewed as behavioural responses or coping mechanisms for navigating the chronic trauma caused due to these stressors (Meyer, 2003; Tallon, 2014; Rodriguez-Seijas et al., 2020). According to Linehan, one of the pioneer researchers in BPD, an invalidating family environment is a pertinent factor in the development of BPD in adolescents (1993). However, the sociocultural mediating factors of BPD have not been thoroughly researched (Crowell et al., 2009), which is why many individuals who have experienced traumatic stress for a long period of time can in fact be misdiagnosed as having BPD (Hodges, 2003).
Despite a clear link between trauma and BPD, it is surprising to note that BPD patients are not generally screened for trauma or considered for treatment of the same (Zimmerman, 1994; Tallon, 2014). Even though the latter has better prognosis (Cloitre et al., 2010). Many clinicians lack the professional knowledge and skill to assess trauma, and thus might ignore its manifestations (Tallon, 2014). Additionally, it has been seen that in clinical settings, the term ‘borderline’ is used not just as a diagnostic label but one which describes complicated patients, who are not very easy to work with (Heightman, 2014). This leads would-be professionals to adopt negative attitudes harboured by their colleagues and instructors towards patients with BPD, during their training, which later manifests into a clinician’s bias towards the same group (Heightman, 2014). This potentially influences how much effort they put into understanding an individual’s problem before diagnosing and labelling them as borderline. While these factors about a clinician’s shortcoming are true for the general population, they become excaraberated when combined with their cultural incompetence. Clinicians may misread normal behaviour as pathological with regards to sexual minority individuals, due to the lack of understanding about the differences between heteronormative and non-heteronormative cultures (E.K Schwartz et al., 2019).
Apart from the clinican’s bias and lack of recognition of trauma in BPD, one important factor which pertinently contributes to the overdiagnosis of this disorder is the lack of accurate assesment techniques. Majority of the diagnoses of BPD simply seem to describe behaviours and symptoms instead of exploring them, thus leading to imperfect diagnoses (Saakvinte et al., 2000). Most importantly, these categories and characteristics of BPD in which individuals from sexual minorities are placed, are intangible or conceptual in nature, and instead are arrived upon in committee meetings (Summerfield, 2008). It must be noted that mental disorders cannot be neatly distinguished from each other, as “categories of mental disorders are not complete discrete entities with rigid boundaries” (Kendell and Jablensky, 2003). To ensure that individuals belonging to the sexual minorities are not misdiagnosed and mistreated with BPD, stigmatising their already stigmatised identities, the way forward is to enhance the availability of queer affirmative psychotherapies (Johnson; 2012) and facilitate trauma focused treatments (Tallon, 2014).
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