Self-Harm as Diagnostic?

In February 2025 I invited ‘unanswered questions’ about self-harm and throughout March 2025 and beyond I will be responding to these questions in a series of blogs. In these blogs I draw on my personal and professional experience, as well as survivor and academic literature. The purpose of these blogs is to bring together a range of perspectives and pose ideas and questions for further reflection. I welcome feedback and questions – thanks for reading!

The Unanswered Question(s): What are your thoughts on how self-harm may be linked to diagnostic criteria of psychiatric diagnoses, or to stereotypes of certain psychiatric diagnoses, and how can that impact on the way help is (or is not) provided? AND Self harm is often associated with the highly controversial diagnosis of EUPD or BPD. Do you think people outwith mental illness “circles” are aware that self harm isn’t specifically a personality disorder thing?

I thought this blog would be easy to write, but it’s actually been quite a challenge. Hard to know where to start, hard to know what to say that doesn’t feel like a rehash or summary of information and thinking that’s already out there. There has been a lot written about this, especially in survivor circles, and I’ve been wrestling with trying to say something that’s somehow different or original. So, I’m hoping this blog, while it might not be new information, will be thought-provoking.

Definitions, Criteria and Labels

In mental health, definitions and criteria for diagnoses are defined either by the Diagnostic and Statistical Manual Version 5 (DSM-V), which is produced by the American Psychiatric Association, and the International Classification of Disease Version 11 (ICD-11), produced by the World Health Organisation.

Outside the specific disorder of Non-Suicidal Self Injury that is listed in the DSM-V, self-harm is listed under the diagnostic criteria for one diagnosis – Borderline Personality Disorder or Emotionally Unstable Personality Disorder. (I’m not going to go into huge depth on the debates around this diagnosis in this blog, but for clarity: it’s controversial, it’s harmful and if you’re involved in any work that involves this diagnosis, you should ensure you are well-informed about the impact this label can have. Some people find it helpful; many people find it harmful.)

Talk to anyone who supports people who self-harm and it will quickly become clear that people use self-harm for a wide range of reasons, and self-harm can be associated with many mental illness’ diagnoses and none. From as far back as survivor literature and shared experience in this area exists, it’s clear people are using self-harm in response to a range of experiences. Yes, dealing with intense and unbearable emotional experiences are in there, but so are command hallucinations, compelling intrusive thoughts and the terror of being bugged or being infested by insects.

Going Round in Circles

So, to my mind, it’s quite a loaded statement to include self-harm as part of the diagnostic criteria for only one diagnosis; and for this not to have changed since 1980 and the publishing of the DSM-III. Research shows other experiences and diagnoses such as dissociative disorders, eating disorders and depressive disorders are also associated with high rates of self-harm, but nowhere else does it show up in specific criteria that can be used to diagnose people.

I’ve found that this can sometimes support a very circular argument that goes something like this: They self-harm because they’ve got BPD AND they’ve got BPD because they self-harm.

It might not be intended like that, but the association can be so strong that it becomes thought of as an explanation in itself. And I’m sure it’s no surprise that I’m going to say, that a circular explanation like this not an explanation, it’s a conversation stopper. It can FEEL like an explanation, but I can assure you, it is not. If I say: they like tea because they’re British AND they are British because they like tea, I still don’t know WHAT it is about ‘Britishness’ or that person or indeed tea that means they like tea, or WHY that is the case. (NB: I am British and I do not like tea; I compounded this error by marrying an Indian…)

Systemic Stigma

Looking at research in this area, sheds a little more light on both the emphasis on self-harm as indicative of BPD/EUPD, and the lack of curiosity this seems to engender when people seek help for their mental health.

Research demonstrating clear stigma and biases around the BPD label goes back several decades. This includes work which shows that purely the addition of the BPD label in a case study had a significant impact on clinician optimism; work which showed higher rates of social rejection and perceived dangerousness being associated with people with BPD by trained mental health workers; reviews confirming that much stigma around BPD comes from within the mental health system; and reviews showing individual and structural stigma towards BPD. I could go on, there’s lots. In 1988, Lewis and Appleby published a paper entitled: Personality Disorder: the patients psychiatrists dislike and in 2018, Chartonas et al showed that similar attitudes still prevailed in Still the Patients Psychiatrists Dislike?

What about self-harm? Research shows similar findings of significant stigma, both in the wider public, general health and mental health services. There is also evidence that this stigma impacts on the number of people seeking help for self-harm.

Further parallels in the association between self-harm and the BPD label can be seen in the common, stigmatising language that can become attached such as ‘attention seeking’, ‘manipulative’ and ‘demanding’. I’ve sat in meetings where I’ve had to request that other participants do not repeatedly refer to other humans as ‘self-harmers’ or ‘BPDs’. In fact, it was only in 2022 that the Royal College of Psychiatrists, the UK-wide membership body for psychiatrists, promoted training describing people with a BPD label as a ‘thorn in the flesh’ of clinicians. Many services also exclude people on the grounds of self-harm (too risky) or BPD diagnosis (too risky and too complex).

Intrinsically Linked

Not to labour the point, but in many settings and mindsets, self-harm and the BPD label are intrinsically linked and tantamount to the same thing. And although it’s not comfortable to think about, the stereotypes attached have significant, negative impacts on people’s experiences of seeking and receiving support. As research shows that negative attitudes and beliefs about both people who self-harm and who have a BPD label are dominant in health services, it would be more of a surprise if people were getting consistently positive and constructive treatment.

In time pressured, outcome driven services and institutions, it makes sense to reach for easier and more tangible answers. If people self-harm because they have BPD and people have BPD because they self-harm, then we have a clear answer. There’s no need for curiosity, or further reflection.

If we step back and consider all the myriad experiences and reasons that have brought people to where they are today, that takes a lot more time, it’s a lot harder, but it’s a lot more illuminating and likely to result in a much better understanding, relationship and impact on that person’s life.

Taking an Anti-Oppressive Stance

As in other areas of anti-oppressive practice, when someone seeks support for self-harm, or seeks support while being labelled with BPD, or indeed both, they shouldn’t have to prove themselves. Prove that they are a worthy person and ‘not like the others with this label or who do this’; prove that they have experienced negative, unhelpful and potentially hostile responses to their need for support; prove that they are trying to exist and get their needs met in a system that is prejudiced against them at institutional, systemic and individual levels.

The conversation around BPD and self-harm feels very circular and like it hasn’t moved on in the 20 years, perhaps even going backwards. And it’s not an abstract, academic conversation, stigma and stereotypes affect people’s lives, their safety, their continued existence. Having been on the receiving end of both, I have never found the words to adequately convey the anguish and terror of being on the receiving end of services where it seems more important for them to be right than for you to be alive.

Only Human

The options are clear now: keep talking or be the change you want to see. Working and relating to people in this way isn’t easy, it takes time and self-reflection, and the work is never done. As an amazing colleague of mine says regularly – working in this way is brave, whichever role you are in, receiving or offering support. But I can assure you it is worth it. There is humanity in everyone, but if you’re not offering humanity, you’re unlikely to bring yours to the fore.

Whenever I run training, people say to me ‘but I’m not trained in mental health’, fearful of their lack of academic knowledge. But, in the end, research and models and theories only take us so far, they can’t teach us to be human, we do actually already know how to do that. And a little human connection without assumption or prejudice goes a long way.