This diagnosis belongs in the bin — it's much more likely to be applied to women

There’s a mental health diagnosis that’s applied three times more often to women than men. That should give you pause for thought alone.

But then, add to that the fact it may be diagnosed after only a brief encounter (not a full assessment) by a clinician who has never met you before; at the point when treatment for some other diagnosis is deemed to have "failed" for example when you don’t recover quickly from depression or an eating disorder; when you are told you are "not engaging" (even though the therapist has responsibility to engage you too).

Or maybe you are deemed "unsuitable for this service", or "too difficult to manage" because you are harming yourself. What is this diagnosis? It’s Borderline Personality Disorder (BPD), sometimes known as Emotionally Unstable.

According to the DSM (the Diagnostic and Statistical Manual of the American Psychiatric Association) people with BPD have a pervasive pattern of instability in interpersonal relationships, self-image and affect (mood), in addition to marked impulsivity and "self-injurious behaviour".

You need five out of nine different symptoms to get the diagnosis of Borderline Personality Disorder but if you are female and self-harm the sad truth is that you may be lucky to get a different one. It’s a sticky diagnosis too. It can stay with you for decades and colour the way that every other health professional in your life behaves towards you.

We do know from research that for people who have these kinds of psychological difficulties there are therapies that can help them recover but these may be painfully difficult to access on the NHS.

But most don’t get any treatment. Some get discharged from care completely and just told to go away. Those who cause most concern because of self-harm get sent to rehabilitation units and are sometimes locked away for years, often at great expense and of doubtful benefit.

Of young women known to mental health services in England and Wales who take their lives before the age of 25, a quarter are believed to have "personality disorder". More than 50 percent of those given this diagnosis who take their lives are women too (that’s a higher proportion of women than in the general population where three times as many men take their own lives as do women).

But what has happened to these people, and why are so many women being given the diagnosis of "borderline"? Many have experienced appalling trauma in their lives. Women are at higher risk of sexual, physical and emotional trauma in childhood, and physical and sexual violence from men in adulthood.

As a result, many prefer the diagnosis chronic Post-Traumatic Stress Disorder or c-PTSD. But there are others who don’t describe any history of trauma except that they’ve experienced in mental health services – which can be considerable. Amongst these, as the psychologist Jay Watts argues very convincingly, are those women who are suffering from the worse kind of period problem, Premenstrual Dysphoric Disorder, which can have a severe enough impact on your mood to make you feel suicidal.

Some are autistic, which has been often missed in women, as it was, for many years, thought to be only present in boys. Others, as I’ve met in my career, may have undiagnosed bipolar disorder, and I’d add that when a woman fails to recover from depression in her middle years, too often "personality" is blamed rather than the possibility she may be perimenstrual.

A great American psychiatrist George Vaillant said that the beginning of wisdom for a professional was never calling a patient "borderline". That it says more about how the therapist feels about the patient than what the patient is telling them. They are just being "difficult women".

Diagnoses are useful in psychiatry for helping us predict what treatment may help a person. Some people do find them useful for understanding themselves. But most of the women I’ve met who have been called "borderline" have been labelled without any proper assessment or understanding of what their problems really are or what sort of intervention or therapy is really needed to help them.

It's beyond time we stopped using the term "borderline". It belongs in the bin.

Out of Her Mind: How We Are Failing Women’s Mental Health and What Must Change by Dr Linda Gask is published on October 10 2024 by Cambridge University Press (HB, £20)