Borderline Personality Disorder: A Difficult Diagnosis

borderline personality disorder: a diffidcult diagnosisA client’s diagnosis of Borderline Personality Disorder is one of the most difficult ones to make.

The complexity, structure and never ending aspects of BDPD are, for many of us, frightening to label. A person paying with insurance fears it will always remain on record.

Many have suggested it is the goulash of disorders; one that is used when all else do not fit criteria.

Case In Point

Sarah is a 29-year-old Caucasian female who owns her own business. Sarah was seen in my office for the purpose of substance assessment following an arrest for operating while intoxicated (OWI) and upon referral from her attorney.

Sarah is open, honest and wanting to be accepted by others (to a fault). She is involved in numerous volunteer roles as well as specializing in special events in particular weddings. She has been regarded by others as a hard worker with solid worth ethic. Sarah shared no risks or liabilities that could interfere with changes she might need to make in her life.

Chemical Use History

Sarah stated her first drink was wine at age 16 and did not pick up another drink until she was 21 (did not like the taste). Sarah suggested she was a social drinker at best. She stated that she began smoking marijuana when she was 16 and has used it off and on since then (medical marijuana card) to reduce anxiety.

She has a long history of prescribed medications for PTSD relating to anxiety and depression but stated there has been no abuse of prescription medication. Sarah had no history of recovery or treatment history. She constantly stated the alcohol was not what was puzzling her rather the anxiety within inside of her that never seemed to go away (knot in stomach).

Sarah indicated alcohol issues from both parents. Mother had a severe 10-year binge of alcohol abuse and now has five years of recovery time. Father, until recently, was regarded a heavy closet drinker. The client stated that her maternal grandfather had severe alcoholic tendencies.

Family History

 Currently, the client stated she has a guarded relationship with parents. Numerous issues related to trust from the past are, at times, severing her relationship with divorced parents.

She suggested that she has numerous healthy friends but has, at times, been involved in needy relationships with men that have generated enabling behaviors, not always healthy emotionally or physically for her.

She shared numerous events in her life related to her relationship with her parents that have caused diagnosed PTSD symptoms along with adjustment disorders generating anxiety and depression. The effects have had relying on prescribed medications  since the age of 9.

Sarah stated she has seen therapists along with taking medications to overcome the after effects of PTSD. Suppressing her feelings has resulted in symptoms of depression which developed into anxiety issues.

She has a tendency to develop co-dependent relationships out of the need to be accepted. Self-esteem has been an issue most of her life and she has a tendency to be over accepting, anxious, fearful and a worrier who has difficulty asking for help.

She has issues of not accepting herself and a limited her view of herself.


Upon reviewing Sarah’s history, what do we find? Should she be diagnosed with PTSD because of her past relationship with her father? Or may it be a result of substance abuse in combination with anxiety and/or depression?

Some suggest that is may be a mixture of all of the above and decideto give Sarah an Adjustment Disorder.

After a few sessions, other more disturbing thoughts come to light. Further testing suggested that Sarah appears to fit Borderline Personality Disorder and Dependent Personality Style. Sarah began, over a short span of time, an irritable, depressed and moody aspect to her personality and was easily able to experience both anxiety and depression.


Melinda Smith, M.A. and Jeanne Segal, Ph.D. in May 2016 in an article entitled: “The 9 symptoms of borderline personality disorder” in reviewed nine key cues pf suffering with BPD.

  • Fear of abandonment. People with BPD are often terrified of being abandoned or left alone.
  • Unstable relationships. People with BPD tend to have relationships that are intense and short-lived. Relationships either seem perfect or horrible, with nothing in between.
  • Unclear or unstable self-image. When you have BPD, your sense of self is typically unstable. Sometimes you may feel good about yourself, but other times you hate yourself or even view yourself as evil.
  • Impulsive, self-destructive behaviors. If you have BPD, you may engage in harmful, sensation-seeking behaviors, especially when you’re upset. You may impulsively spend money you can’t afford, binge eat, drive recklessly, shoplift, engage in risky sex, or overdo it with drugs or alcohol. These risky behaviors may help you feel better in the moment, but they hurt you and those around you over the long-term.
  • Self-harm. Suicidal behavior and deliberate self-harm is common in people with BPD.
  • Extreme emotional swings. Unstable emotions and moods are common with BPD. One moment, you may feel happy, and the next, despondent. Little things that other people brush off can send you into an emotional tailspin.
  • Chronic feelings of emptiness. People with BPD often talk about feeling empty, as if there’s a hole or a void inside them. This feeling is uncomfortable, so you may try to fill the hole with things like drugs, food or sex. But nothing feels truly satisfying.
  • Explosive anger. If you have BPD, you may struggle with intense anger and a short temper.
  • Feeling suspicious or out of touch with reality. People with BPD often struggle with paranoia or suspicious thoughts about others’ motives. When under stress, you may even lose touch with reality—an experience known as dissociation. You may feel foggy, spaced out, or as if you’re outside your own body.


Had the traumatic past events in Sarah’s life created the backdrop for her potential diagnosis as BPD? Sarah does, at times, exhibit many of the above symptoms of BPD in particular: abandonment, self-harm and the chronic need for approval and acceptance.

At what point does the diagnoses fit the client? The DSM-5 states that five criteria need to be met out of the nine listed.  What happens when at one particular stage in life she is diagnosed with only four symptoms or when a change in therapists suggests six instead of the four symptoms listed by a past therapist?

The diagnosis is important to a degree but I wonder does it label and stigmatize clients to have some incurable mental disorder and find themselves helpless in other issues such as depression and anxiety that have been heightened?

Sarah makes headway but sometimes it does seem endless – two feet forward and one back.

 “The Queen is controlling, the Witch is sadistic, the Hermit is fearfu, and the Waif is helpless.

And each requires a different approach. Don’t let the Queen get the upper hand; be wary even of accepting gifts because it engenders expectations. Don’t internalize the Hermit’s fears or become limited by them. Don’t allow yourself to be alone with the Witch; maintain distance for your own emotional and physical safety. And with the Waif, don’t get pulled into her crises and sense of victimization. Pay attention to your own tendencies to want to rescue her, which just feeds the dynamic.”

–Christine Ann Lawson, Understanding the Borderline Mother: Helping Her Children Transcend the Intense, Unpredictable, and Volatile Relationship


Borderline Personality Disorder: A Difficult Diagnosis

Steve Greenman, MA, LPC, NCC

Steve Greenman, MA, LPC, NCC is a licensed professional counselor (LPC) in northern Michigan who has a passion for reading, writing, music and helping others. He specializes in counseling complex family situations, substance abuse, and parenting. Steve’s counseling philosophy is holistic, approaching each issue on its own merit and evaluating influences to help overcome life’s dilemmas.


APA Reference
Greenman, S. (2016). Borderline Personality Disorder: A Difficult Diagnosis. Psych Central. Retrieved on September 19, 2020, from


Scientifically Reviewed
Last updated: 3 Jun 2016
Last reviewed: By John M. Grohol, Psy.D. on 3 Jun 2016
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