Ethics of Diagnosing Borderline Personality Disorder: Focus on Adolescents

This post was crafted in partnership with the UF-VA Bioethics Unit and Florida Community Innovation, a 501c3 nonprofit.

In October 2023,  Dr. Michael Shapiro presented a Grand Rounds talk with the UF-VA Bioethics Unit about the ethics of diagnosing Borderline Personality Disorder (BPD). A recording of the talk is available on the UF Department of Psychiatry website.

Watch the recording here!

In his talk, Dr. Shapiro focused on Borderline Personality Disorder (BPD), which is characterized by intense instability of interpersonal relationships, self-image, impulsivity, and excessive emotional reactions. 

According to the Mayo Clinic, an example of instability within relationships is idealizing someone one moment, and then suddenly believing that person is cruel another moment. Despite people diagnosed with BPD wanting to have stable and healthy relationships, an intense fear of abandonment often gets in the way of this. 

Stigma for BPD Diagnosis in Adolescents

We learned from the talk that BPD is a disorder many psychiatrists avoid diagnosing and disclosing in adolescents, because of beliefs that diagnosing personality disorders in adolescence is not reliable – psychiatrists believe the disorder is not permanent when it manifests in adolescents.

According to Dr. Shapiro, psychiatrists may also decline to diagnose BPD in adolescents because personality disorders in adolescents do not appear in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Despite many physicians holding these beliefs, Dr. Shapiro confirmed their inaccuracy during his talk. He discussed how recent evidence demonstrates that a BPD diagnosis in adolescence is just as reliable as one in adulthood, and how adolescents with BPD may benefit from early intervention via a diagnosis. 

During a post-talk interview with FCI, Dr. Shapiro mentioned the “Good Psychiatric Management of BPD,”  a manual that helps psychiatry trainees provide better treatment to those diagnosed with BPD. 

This resource — along with others — helps professionals gain knowledge on how to appropriately diagnose and treat patients with BPD, which lessens the likelihood that psychiatrists will withhold diagnoses. 

During this interview, Dr. Shapiro also discussed how an accurate diagnosis of BPD helps individuals get the evidence-based treatment they need. Folks with BPD often need very long-term care, and an accurate diagnosis will avoid push back from insurance companies for such long-term care. 

Why withhold a diagnosis? 

Another common reason Dr. Shapiro gave for withholding a BPD diagnosis is how stigmatizing it can be for the recipient. While this is true, he clarified how it is not the label of BPD alone that is stigmatized. Even without knowing their diagnosis, adolescents with BPD were still more likely to experience stigma compared to others. 

“Stigma is real, whether or not we make a diagnosis,” Dr. Shapiro said in the talk. “We should be educating people both about the diagnosis and the unfortunate stigma that’s attached to it.”

Healthcare professionals should diagnose, disclose, and document BPD in adolescents, said Dr. Shapiro. The diagnosis can foster trust between psychiatrists and their patients, and emphasizes patient autonomy. By knowing their diagnosis, patients will be equipped to have a say in their treatment plan.  

Dr. Shapiro emphasized how people with BPD, in particular, will benefit from the empowerment gained from their diagnosis being shared, since they often lack trust in others and come from childhood environments where they felt invalidated. 

“So this is a group of people who feel invalidated and that they can’t trust anybody, and that’s the group of patients you’re not gonna tell them what their diagnosis is,” Dr. Shapiro told the crowd. “A diagnosis helps people with BPD feel validated and in charge of their treatment plans.”

Receiving a diagnosis can give patients the treatment knowledge necessary to increase their wellbeing. 

For example, Dr. Shapiro mentioned that teens with BPD are more likely to have issues with substance abuse as adults. This is helpful for a teen with a BPD diagnosis to be aware of, so they know to be hesitant about engaging with substances.  

Should BPD be considered a personality disorder?

Personality disorders, said Dr. Shapiro, are typically associated with stability, enduring over time, and symptoms that don’t depend on situational factors or are transient. Dr. Shapiro emphasized how BPD is unstable, becomes less evident over time, and symptoms tend to result from environmental stressors and are transient. He also mentioned how BPD has many similarities with Post Traumatic Stress Disorder (PTSD). 

Nevertheless, many still believe a person being diagnosed with BPD means they have multiple personalities among other myths. 

In our interview with him, Dr. Shapiro said that celebrities being open and honest about their experience with BPD would be useful in getting more people to understand the disorder. 

“I wish we had more celebrities who would come forward and be good ambassadors, like we do for other illnesses,” he said. “But I am concerned that celebrities may not be receiving the most high-quality care, either. Pete Davidson has publicly announced that he has BPD, as has the former NFL player Brandon Marshall. Unfortunately, they are few and far between, and there’s no reason to think that celebrities are immune to the diagnostic biases that still exist.”

Dr Shapiro believes that the internet and social media can be sources of both helpful AND inaccurate information. “Part of this, in my opinion, is still related to overall stigma associated with mental health conditions,” he said to us in the post-talk interview.

“Only for mental illnesses do people with no clinical background try to diagnose their friends and family,” said Dr. Shapiro in the post-talk interview. “How many times have you heard someone say about themselves or someone else ‘I think they’re bipolar’ without any real clinical understanding of what that means? We don’t try to diagnose rheumatoid arthritis in our friends.”

To close his talk, Dr. Shapiro discussed how psychotherapy is especially helpful in cases of BPD, and the earlier teens are diagnosed with it, the faster they can receive this treatment. 

He also included data from a study about the trajectory of BPD over ten years which shows that many BPD symptoms get better over time. This information would be very valuable for a patient diagnosed with BPD to know, since it may provide them with hope. 

The ethics of AI in diagnosing BPD

As a civic tech nonprofit, after watching Dr. Shapiro’s talk, we at Florida Community Innovation couldn’t help but wonder: how will AI tools change the conversation about BPD diagnoses for adolescents?

From what we found online, AI can help with distinguishing between BPD and similar diagnoses, such as bipolar disorder. Bayes et al. (2021) used machine learning (ML) to compare these two disorders and found that ML classification had an overall accuracy of approximately 70%. 

A larger data set would allow for even more accurate predictions. These predictions will allow for greater clarity about the differences between these disorders and for more accurate diagnoses. This greatly helps people suffering with these illnesses, as an accurate diagnosis means they have higher chances of receiving the appropriate care they need. 

While AI may be helpful in making reliable diagnoses, Jan et al. (2021) points out how it is also important for medical professionals to be aware of the risk that working with sensitive medical data poses. It is essential for measures to be implemented so that patient privacy is protected. Overall, AI in medicine is proving to be a valuable tool, but it is key that this tool is regulated and carefully used. 

Author Bios

Esmeralda Hechavarria is a third-year Psychology and Statistics Double Major. She is thrilled to be part of FCI as she aims to utilize her data science skills to create positive change in her community. Esmeralda is particularly passionate about promoting equitable access to education for students of all backgrounds and advocating for the LGBTQ+ community! 

Olivia Zhang is a first-year data science and geography major passionate about supporting community-centered initiatives through research and data storytelling. She is interested in applying tech for social good because of the opportunities to build connections and share stories.