Borderline Personality Disorder: Is It Really a ‘Women’s Issue’?
What Is BPD?
BPD is one of a set of personality disorders. “The hallmark is contracted instability in relationships,” says Jackie Mascher, PhD, a psychologist in private practice in Boston who is also a lecturer at Tufts. “This is an interpersonal diagnosis, meaning that it relates to how a person is with other people.” There are nine criteria with which to diagnose BPD and five need to be met to make a definitive diagnosis, according to Mascher. These include: frantic efforts to avoid abandonment, real or imagined; pattern of unstable and intense relationships; lack of a sense of self; impulsivity including one or two areas of potentially dangerous behavior such as self-harm and drug use; recurrent suicidal gestures such as threats; emotional instability; chronic feelings of emptiness; inappropriate anger; paranoia or disassociation.
According to the DSM-IV (the handbook used to diagnose psychological disorders), it is estimated that 2% of the population can be diagnosed with BPD. Of that 2%, 10% are found in the outpatient population and 20% in inpatient treatment settings. “Also — and this highlights how problematic this is as a feminist issue — it is diagnosed 75% of the time in women even though we have clear data showing that BPD is found equally among genders,” says Patrick Rafferty, PhD, a clinical psychologist in private practice in New York City.
And the research bears that out. The Journal of Personality Disorders recently reported a multinational clinical trial sample of gender difference in BPD and found “an unexpected convergence between genders in our BPD sample.” The paper ended with this sentiment: “Rather than [exclusively] asking how men and women with BPD are different, perhaps it is time to begin to ask, ‘Why aren’t they’”?
Perception of BPD as a ‘Women’s Disease’
So why the disconnect between the data and the DSM basically calling this a women’s disorder?
“What this would tell me,” says Rafferty, “is that there are a lot of mental health practitioners who are over-diagnosing this disorder in women likely because of the stereotypical ideas of ‘hysterical’ women.” And Mascher concurs: “I don’t think anyone disputes the fact that women are diagnosed more but that could just be that they present more for therapy. Because BPD is so deeply a developmental disorder and because we so profoundly raise boys and girls differently, it would make sense that people might label men more narcissistic and sociopathic and women with more BPD…. Also, it is hard to tease out how many men have BPD because they often avoid relationships and don’t end up in therapy.”
Just the idea that more women have BPD than men is a throwback to the idea of the hysterical woman who can’t hold herself together. But it is a societal projection and just not true, according to people who study the disorder and those who work with BPD patients. “Do men get the flu more than women?” asks Rafferty. “It is the same with BPD — there is no gender aspect.”
Part of the problem with this disorder, Rafferty says, is that it is defined by symptoms rather than a cause — such as trauma. (While experts don’t know the actual “cause,” BPD is thought to be brought on by a combination of genetics and environment and often can be traced back to a stressful childhood.) “Secondly,” says Rafferty, “it is defined by antiquated and likely gender-biased ideas about women, their personalities, and how they respond to trauma.”
Mascher says there are three aspects to the gender question and BPD:
- Because of the way our children are socialized, they may develop different aspects within BPD.
- Men and women present at different rates for different reasons.
- Clinicians perceive patients differently and over-diagnose women with BPD and under-diagnose men.
Depending on the orientation of the practitioner, treatment for BPD usually consists of either long-term psychoanalytic therapy and/or dialectical behavioral therapy (DBT). DBT is a combination of cognitive behavioral therapy, mindfulness and emotional awareness. Both therapies have a good track record for treating BPD, however it usually is a long-term endeavor.