A mental health diagnosis is the name that we (mental healthcare providers) give to a particular set of symptoms (see more on that here) that often go together.
In the United States, we use a book called the Diagnostic and Statistical Manual of Mental Disorders (DSM). It’s a great big book that has around 300 mental health diagnoses in it. For each one, it includes a list of symptoms that are commonly associated with the diagnosis.
The DSM is currently in its fifth edition. Each time it is updated, it adds new diagnoses and removes some old ones. Sometimes the criteria for a diagnosis are changed.
BPD first appeared in the third edition of the DSM in 1980, and the symptoms listed were unchanged between the fourth and fifth editions. For a complete history of the diagnosis, see [http://www.bpddemystified.com/what-is-bpd/history/]
How and why are diagnoses formed?
Diagnoses are formed when someone in the mental health world needs to study a particular group of people to develop a new treatment or medication.
Think about it this way: if you are studying birds, you need to know what a bird is so you don’t accidentally include bats and bees. You would need to really specifically describe what a bird is – and what it isn’t.
You might say that the symptoms of being a bird are: having feathers, laying eggs, flying, and living in trees.
But other animals lay eggs, fly, or live in trees. Does that make them birds? And what about birds that don’t fly, like ostriches and chickens? Does that make them not birds?
So you might switch up your symptom list to say: a bird has to have feathers and lay eggs. It may or may not fly or live in a tree.
As you can see, one diagnosis (like bird) might include a whole lot of variety (like chickens, ducks, eagles, vultures, and pigeons).
That’s how mental health diagnoses work too. We can describe symptoms that most people have in common, but there will be a lot of differences on an individual level.
What do we do with diagnoses?
In the academic world we use diagnoses to study, develop and validate treatment, and to create and test new medication.
In the treatment world, we use diagnoses to figure out what kind of treatment is the best place to start. There are a lot of different types of therapy out there, and some of them work better for certain diagnoses. Just like Vitamin C is good for a cold, but not for a broken leg – knowing a diagnosis helps us know what treatment to use first.
We also use it to communicate with insurance companies – to explain why we are asking for reimbursement for certain types of treatment.
So what does a mental health diagnosis mean?
Depending on your point of view, it either means very little, or it can mean quite a lot.
In my personal opinion, a diagnosis can be useful because it makes people feel understood and validated.
When people learn about BPD, they often express relief that there is a name for what they are experiencing, and that they are not alone. It can explain why previous treatments or medications didn't work and help people feel less ashamed. It also means there are different treatments available, which can bring a lot of hope!
In other ways, a diagnosis is less important. Like we talked about above with bird example, a diagnosis doesn’t give you enough information to know exactly what every individual with the diagnosis is experiencing. It’s very general, and there might be a lot of information out there that doesn’t apply to you.
And sometimes, a diagnosis can cause harm. Every now and then people will over-identify with their diagnosis, to the point where they use it as an explanation of all their ineffective behavior. “I can’t control it, I’m ____.” In other situations, if there is a lot of stigma attached the diagnosis, it might actually prevent someone from getting compassionate or high-quality care.
So is a diagnosis good or bad? Neither. It’s what we do with the information that matters. If we use a diagnosis to find new pathways towards healing, I’m all for it. If we use it to excuse poor behavior or harm others, then I’m strongly against it.
It's important to note that all emotions, and the way we talk about emotions, are cultural constructs. Babies aren't born knowing the difference between "irritation" and "frustration" and "anger" - those are terms that we have in the English language that describe slightly different ways we might feel when someone or something gets in the way of what we want.
Every language has slightly different words for describing emotions, and every culture has slightly different rules for how to express those emotions.
For example: I grew up in New Jersey, where it is culturally appropriate to express your frustration with strangers by honking your horn at them, or yelling at them to hurry up. Later in my life I moved to Texas, where it would be considered extremely rude to do either of those things.
What does this have to do with symptoms?
In the mental health world, we define symptoms as feelings or behaviors that get in the way of you living your ideal life.
If I'm in New Jersey and I express my frustration by yelling at strangers, that isn't interfering with my quality of life. It would be considered an effective emotion regulation skill, because it allowed me to discharge my frustration and move on with my day.
But if I'm in Texas and I express my frustration by yelling at strangers, that might be a big problem. I might be considered a loose cannon, unpredictable, or aggressive. So the same action would now be considered ineffective - because it has consequences that interfere with my quality of life.
When a mental health professional is evaluating symptoms to make a diagnosis, they're not just looking at the behavior or the emotion itself. They're also looking at whether that behavior/emotion is effective.
A lot of the symptoms of BPD are actually very effective behaviors in the context of a traumatic childhood. For example, a child who puts on a big display of emotion when their caregiver leaves might actually get their attention. This would teach the child that it is okay to act out dramatically when they are afraid of abandonment, and that it is likely to work. So the child is likely to repeat that behavior.
It is only when the child enters adolescence that this behavior starts to impact their relationship with peers, teachers, coaches, and others in their environment. That's when these behaviors would become "symptoms" of BPD rather than effective actions.