Structural stigma and its impact on healthcare for borderline personality disorder: a scoping review

Abstract

Background People with Borderline Personality Disorder (BPD) and their carers/families continue to experience structural stigma when accessing health services. Structural stigma involves societal-level conditions, cultural norms, and organizational policies that inhibit the opportunities, resources, and wellbeing of people living with attributes that are the object of stigma. BPD is a serious mental illness characterized by pervasive psychosocial dysfunction including, problems regulating emotions and suicidality. This scoping review aimed to identify, map, and explore the international literature on structural stigma associated with BPD and its impact on healthcare for consumers with BPD, their carers/families, and health practitioners. Methods A comprehensive search of the literature encompassed MEDLINE, CINAHL, PsycINFO, Scopus, Cochrane Library, and JBI Evidence-Based databases (from inception to February 28th 2022). The search strategy also included grey literature searches and handsearching the references of included studies. Eligibility criteria included citations relevant to structural stigma associated with BPD and health and crisis care services. Quality appraisal of included citations were completed using the Mixed Methods Appraisal Tool 2018 version (MMAT v.18), the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Research Syntheses Tool, and the AGREE II: advancing guideline development, reporting, and evaluation in health care tool. Thematic Analysis was used to inform data extraction, analysis, interpretation, and synthesis of the data. Results A total of 57 citations were included in the review comprising empirical peer-reviewed articles (n = 55), and reports (n = 2). Studies included quantitative, qualitative, mixed methods, and systematic review designs. Review findings identified several extant macro- and micro-level structural mechanisms, challenges, and barriers contributing to BPD-related stigma in health systems. These structural factors have a substantial impact on health service access and care for BPD. Key themes that emerged from the data comprised: structural stigma and the BPD diagnosis and BPD-related stigma surrounding health and crisis care services. Conclusion Narrative synthesis of the findings provide evidence about the impact of structural stigma on healthcare for BPD. It is anticipated that results of this review will inform future research, policy, and practice to address BPD-related stigma in health systems, as well as approaches for improving the delivery of responsive health services and care for consumers with BPD and their carers/families. Review Registration: Open Science Framework (https://osf.io/bhpg4).

Implementing dialectical behaviour therapy in routine practice: an evaluation of a national CAMHS DBT service for adolescents

“…MSI-BPD, BEST), in line with clinical guidelines, young people were not automatically diagnosed with BPD if they met criteria (National Collaboration Centre for Mental Health, 2009; Swales, 2022). Instead, a discussion was had with young people and their families about the diagnosis, its strengths and limitations, differential diagnoses such as complex post-traumatic stress disorder, and the potential stigma associated with BPD (Klein et al ., 2022; Lamb et al ., 2018; Swales, 2022). The use of diagnostic terminology was guided by what was identified as clinically helpful in collaboration with the young person.…”

“…BPD is not typically diagnosed with diagnostic manuals in those under 18 years old. There is understandable hesitance to associate specific struggles for adolescents with this label, as personality is still developing and to protect against the potential stigma and criticisms related to the BPD construct (Kaess et al ., 2014; Klein et al ., 2022; National Collaboration Centre for Mental Health, 2009; Swales, 2022). However, emerging BPD symptoms in adolescents are associated with an increased likelihood of long-term difficulties with BPD and high costs to young people’s health (Chanen et al ., 2017; Winograd et al ., 2008).…”

Attitudes of psychiatry trainees towards patients with borderline personality disorder: Does the stigma begin during training?

“…It has also been widely reported that the capacity of existing health services to meet the complex needs of patients with BPD is limited (Iliakis et al, 2019; Warrender et al, 2021; Zimmerman, 2015). A review completed in 2022 (Klein et al, 2022) found that myths regarding the untreatability of patients with BPD continue to perpetuate the stigmatizing culture, attitudes and practices within health‐care systems. Despite BPD being treatable with evidence based psychotherapy (Lynch et al, 2007), clinicians frequently encounter barriers such as limited service availability of these treatments (Carrotte et al, 2019; Hermens et al, 2011).…”

“…To the authors' knowledge, this study is the first to take a comparative cross‐sectional measure of attitudes towards patients with BPD, within different stages of a formal psychiatry training programme. Given the well‐established link between positive perception and improved treatment outcomes (Klein et al, 2022), it is imperative that clinicians maintain empathy and treatment optimism towards patients with BPD. This study has shown that more advanced psychiatry trainees have less empathy, reduced treatment optimism and a more negative attitude towards patients with BPD, when compared to junior trainees.…”

Establishing efficacy and effectiveness in the treatment of personality disorders

“…This is related to greater treatment reluctance and past abuses, particularly in areas such as intellectual disability where there is universal suspicion of all kinds of experimentation (Oliver et al, 2002). In personality disorder, there are particular problems associated with stigma (Klein et al, 2022; Ring & Lawn, 2019).…”