Pathologizing Disagreement: A Form of Epistemic Injustice
Pathologizing Disagreement: A Form of Epistemic Injustice
I have read the recently published paper by Ruffalo and D’Agostino on the reality of borderline personality disorder (BPD)1 with some concern—a concern further fueled by an unpleasant debate on social media. As a psychiatrist, I fully recognize that individuals diagnosed with borderline personality disorder (as conceptualized in the DSM) experience genuine suffering and can meaningfully benefit from psychotherapy. However, I also acknowledge that for many individuals, myself included, a diagnostic label has not been helpful; on the contrary, it has often felt stigmatizing or confining.2 This is not unique to BPD but may be particularly pronounced in this diagnosis and has led to reflections on the overall rationale behind organizing our thinking around diagnoses.3
Unfortunately, the current debate doesn’t seem particularly productive. It left me wondering whether this is yet another instance of a psychiatric discussion derailed by a lack of conceptual clarity, making it unclear what the disagreement is truly about. The authors argue that BPD is indeed real, while individuals involved in the countermovements often feel that being labeled is unhelpful.
Conceptual clarity may prompt us to start with a conceptualization of what is meant by the reality of a diagnosis in the first place. There are neither necessary nor sufficient criteria for defining what constitutes a disorder or diagnosis. What we choose to understand through a medical lens is shaped by cultural, historical, and contextual factors,4 and may be better understood as practical kinds rather than natural kinds that carve nature at its joints.5 This basically challenge the concept of describing diagnostic categories as grasping reality. The value of a diagnostic construct lies not in objective reality but in the practical experience of helpfulness.
A scientific discipline such as psychiatry should, in my view, be sensitive to countermovements and critical voices represented by people with lived experience and first ask itself: are there simply too many “unhappy customers” to legitimize a certain diagnostic construct? If so, perhaps the diagnosis is failing at its most basic purpose: to be helpful.
As I read the paper, there is an unfortunate lack of responsiveness; instead, the critique is being interpreted as further evidence that these individuals are disordered. This reflexive mechanism, pathologizing dissent, has a long and troubling history in psychiatry. In my understanding, this reflects what has been termed epistemic injustice: the dismissal of a person’s testimony based on negative, prejudiced assumptions about their credibility as knowers.6 It is deeply invalidating, whether in an academic journal or a clinical encounter, to have one’s disagreement framed as further evidence of one’s pathology. The paper also pushes back against the growing emphasis on trauma as an explanatory framework. While I agree that trauma should not become the new "single-cause narrative," we must also respect and support people’s own narratives of their suffering—a core principle emphasized in WHO’s recent guidelines on the foundation of contemporary psychiatry.
What I would urge, instead, is that professionals practice epistemic humility.7 Through an acknowledgment that diagnostic systems are 1) tentative models and 2) one among many models to grasp human suffering, we must become more responsive to critical voices and open to alternative narratives.8 I find the paper exhibits an overconfidence in the medical model, reinforced—perhaps unconsciously—through rhetorical strategies that discredit dissent. This is a way to preserve power and privilege a specific way of thinking that excludes explanatory pluralism. I propose, as I have done earlier, that pluralism and dissensus9 be embraced as sources of innovation. Finally, I will repeat the quote from Freud: “It is inherent in human nature to consider a thing untrue if one does not like it.” Perhaps the critique is more valid than we, as professionals, are comfortable admitting.
1 D`Agostino A Ruffalo, M. On the Reality of Borderline Personality Disorder. Psychiatric Times 2025; 42.
2 Speyer H. Stories that trap us and stories that save us. Psychiatr Rehabil J 2024; : No Pagination Specified-No Pagination Specified.
3 van Os J, Guloksuz S, Vijn TW, Hafkenscheid A, Delespaul P. The evidence-based group-level symptom-reduction model as the organizing principle for mental health care: time for change? World Psychiatry 2019; 18: 88–96.
4 Marková IS, Berrios GE. Research in Psychiatry: Concepts and Conceptual Analysis. Psychopathology 2016; 49: 188–94.
5 Stein DJ, Nielsen K, Hartford A, et al. Philosophy of psychiatry: theoretical advances and clinical implications. World Psychiatry 2024; 23: 215–32.
6 Fricker M. Epistemic injustice: Power and the ethics of knowing. Oxford University Press, 2007.
7 Solomon M. Five conceptual competences in psychiatry. World Psychiatry. 2024; 23: 233–4.
8 Aftab A, Stein DJ. Psychopharmacology and Explanatory Pluralism. JAMA Psychiatry 2022; 79: 522–3.
9 Speyer H, Ustrup M. Embracing dissensus in lived experience research: the power of conflicting experiential knowledge. Lancet Psychiatry 2025; 12: 310–6.
IDC-11 has done away with a distinct BPD diagnosis. Instead there is a subsection under personality disorders for Borderline Pattern traits. That seems to me the way to go. It ensures that symptoms specific to BPD are supported but with less of the stigma of a personality disorder. It is about balance. Psychiatry doesn’t have all the answers. It wants to pathologise “normal” responses to trauma which the vast majority of those diagnosed with BPD have experienced. Crazy.
I despair of convincing psychiatry to give up power or achieve anything like humility. Its insistence on the idea of “personality disorders” has become an ideological battle which won’t be resolved until psych admits that all of its “diagnoses” are subjective and baseless. It must be the hill institutional psych has decided to die on 😁 - to defend the most indefensible diagnosis or something !