The true stigma in mental healthcare today lies not in immorality, as Erving Goffman argued, but rather in the misdiagnosis that condemns countless individuals, perpetuating cycles of ineffective treatment and amplified distress. Twelve million adults are misdiagnosed annually in the United States–800,000 of these individuals die or become permanently disabled because of this clinical error. Without equitable and standardized diagnostic criteria and tailored, person-centered care, the numbers won’t change, and the harm caused by medical ignorance will continue.
The failure in misdiagnosis has often been seen in response to stigma, shortage of community care, and lack of federal support. The strain caused by misdiagnosis is seen rippling through culture, community, and government–it isn’t just on the individuals suffering. The stress placed on our healthcare system grows with this inability to diagnose appropriately, as does the weight on communities to try to take care of these individuals without understanding how.
As a society, we are currently seeing a rise in mental illness–particularly of note has been the increase in individuals being diagnosed with Borderline Personality Disorder (BPD). BPD affects between 1.6% and 5.9% of the population, yet it is routinely misdiagnosed or overlooked entirely. As an under-researched and over-stigmatized mental disorder, an increase in diagnoses proves concerning. The question arises if these individuals do indeed have BPD, and if so, why did it take until recent years for these individuals to receive their diagnosis? And if the number of individuals continues to grow, why is it so difficult for them to get the help they need?
BPD has the highest suicide rate among all mental illnesses, with 70% of patients trying to take their lives and 10% completing the act. Additionally, people with borderline personality disorder make up 42% of public medical and psychiatric service usage, causing them to fall into a cycle of crisis due to the only widely accessible option for support providing ineffective, short-term interventions. Despite the high level of regular and recurrent hospitalization of these individuals, over 80% of medical professionals admit to discriminating against patients with BPD, often dismissing them as “manipulative” or “attention-seeking.” The same clinicians also disclosed their history of refusing to treat these individuals rather than looking for interventions to reduce their rate of return.
Alongside this, studies revealed that individuals with BPD are often intentionally underdiagnosed with only their comorbid disorders. Clinicians frequently choose to omit a diagnosis and, instead, underdiagnose these individuals to “help” them by not labeling them and burdening them with society’s stereotypes–the same clinicians who have openly admitted to marginalizing and dismissing them themselves. Part of the medical professional’s treatment plan is an inhumane erasure of the issue rather than problem-solving the solution.
This stigma is made worse by the current insufficient diagnostic tools, which further prohibit individuals from pursuing appropriate care and instead drive them toward public services like emergency departments. Ironically, studies have shown that repeated short-term hospital admissions are not only ineffective but can also be harmful for individuals with BPD. Instead, the data in these studies concluded that the most effective intervention is long-term outpatient therapies like Dialectical Behavioral Therapy (DBT), Mentalization-Based Therapy (MBT), and Transference-Focused Psychotherapy (TFP), which have shown remission rates of up to 93% when properly utilized. However, accessibility to these outpatient therapies is extremely limited and often requires an accurate diagnosis, which further perpetuates the cycle of suffering by solely providing a service that is known not just to be inadequate but severely damaging for individuals with BPD.
Given the extent of the stigma and the lack of diagnostic accuracy, these individuals aren’t being offered the resources they need, resulting in a lack of support and a rising need for help. Without being given the tools that modalities such as DBT teach, they will continue to hit a level of crisis that requires the extensive, immediate care of emergency departments. Given the self-shame, discrimination, and invalidation these individuals face, they may also stop seeking care entirely to avoid further harm. Had there been better diagnostic criteria and more compassion rather than judgment and misinformation–such as being labeled as “manipulative” when they are simply using the maladaptive, trauma-rooted language they know to ask for compassion and support for an unbearable depth of pain–what would the suicide rates for those with borderline personality disorder look like today?
With such extreme dismissal from the medical community, there is no urge for research to be conducted on BPD, including its etiology, presenting symptoms, diagnostic criteria, correct DSM-5 classification, and effective treatment plans. As the mental illness with the least amount of funding allocated by the NIMH, there is a consequence of the federal government not prioritizing these individuals in the same way they do for other disorders, such as PTSD and Bipolar Disorder. Personality disorders are omitted from federally funded and sanctioned acts and laws that support individuals with mental illness, including the Affordable Care Act’s Mental Health Parity and Addiction Equity and the Community Mental Health Services Block Grant (MHBG). This also includes the federal government’s influence on health insurance–resulting in personality disorders often not being covered by both public and private insurance.
This ripple effect extends downward to communities–without coverage under the MHBG, communities aren’t allocated the funding or education to support individuals with BPD and other personality disorders. Mental health centers often don’t include resources such as DBT or TFP. They rarely have enough staff to consider adopting these modalities into their current framework. Thus, these individuals continue to suffer without the treatment they need–and with this consistent weight of stigma being applied from every level of society, they have few options. The options become even slimmer if they were initially misdiagnosed and have no guidance on where to get adequate help–if they can get help at all.
To address this rising crisis, we need a multi-level approach:
- Standardize diagnostic criteria and processes across mental health conditions, emphasizing a unified and multidisciplinary approach for psychologists, psychiatrists, emergency department clinicians, and social workers.
- Improve education to include comprehensive training on accurate diagnosis and treatment, especially for severe and persistent mental disorders.
- Expand research funding for conditions like borderline personality disorder to develop more precise diagnostic tools and evaluate treatment efficacies.
- Amend mental health parity laws and insurance company requirements to include coverage for personality disorders.
- Develop community-based resources that provide evidence-based, effective, long-term, structured care for individuals with severe and persistent mental disorders, reducing reliance on ineffective short-term hospitalizations.
- Focus on combating stigma and bias across communities, organizations, and government entities.
We must acknowledge that without a fundamental change in our approach to mental health diagnosis, mental health disorders will continue to rise while, simultaneously, the number of those seeking support continues to decline. Less than 40 percent of individuals with a serious mental illness receive medical care annually. With such a high number of those who do seek medical care being individuals with BPD, you can almost hear their scream for help slowly getting louder–their desperate plea that they are not the immoral outcasts Goffman suggested through his definition of the term stigma. They are misrepresented as dishonest, crisis-laden, attention-seeking, and dangerous individuals. The negligence of underdiagnosing, misdiagnosing, or foregoing diagnosis altogether is not just a medical concern–it’s a concern for public health. Dismissing this crisis not only continues to place an ongoing burden on our medical system and community support services, but it also continues to fuel the suffering and the rising suicide rate of individuals with conditions like Borderline Personality Disorder. We need to break this lethal cycle of misdiagnosis, reduce stigma, and provide adequate, tailored care to these individuals, as well as the millions of Americans alongside them who are struggling with severe, persistent mental health disorders.
Caroline Stephens received her Master of Social Work this May at Silver School of Social Work, New York University. She can be reached by email at ccs341@nyu.edu.
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Title XIX, Part B, Subpart II of the Public Health Service Act; 2022.
