By Brooke Schwartz, LMSW
**Disclaimer: This blog post discusses Borderline Personality Disorder in the context of the gender binary due to the limited research that currently exists outside of it. Borderline Personality Disorder transcends gender, affecting cisgender, transgender, and gender nonconforming individuals — anyone can be diagnosed with Borderline Personality Disorder.**
Mental illnesses have long been represented in media — we’re accustomed to seeing our favorite characters cope with anxiety, depression, and bipolar disorders, among others. But Borderline Personality Disorder (BPD) is largely untouched in media, despite between 1.6 and 6 percent of the United States population (that’s as 14 million people) carrying a diagnosis. When BPD is portrayed in media, it’s predominantly depicted by women (e.g., in Girl, Interrupted, Silver Linings Playbook, and Crazy Ex-Girlfriend). On the surface, this makes sense; as many as 75% of those diagnosed with BPD are in fact women. However, recent research has begun to focus on the fact that while women are more often diagnosed with BPD, rates of the disorder may be more or less equal among men and women.
In exploring gender differences and patterns in BPD, it’s important to have an understanding of what BPD is and how it develops. BPD is a mental disorder characterized by a pattern of instability in mood, behavior, self-image, interpersonal relationships, and impulse control. BPD has both biological and social etiologies. Genetically, those with BPD have been found to have a predisposition to stress vulnerability; socially, those with BPD tend to have lived in invalidating or ineffective environments, or ones that they experience as such. Transactions between one’s temperament (influenced by their genetic predispositions) and their social experience (such as chronic invalidation, adverse family environment, or physical or emotional abuse) can cause individuals to perceive, think about, and relate to themselves and others in inflexible and maladaptive ways. When this results in functional impairment or subjective distress, clinicians may consider the individual to meet criteria for BPD.
Presentation. Women and men with BPD differ in how their symptoms present, which may contribute to the services they seek out and the diagnoses they receive. Women with BPD are more likely than men with BPD to meet criteria for eating disorders, as well as mood, anxiety, panic, and posttraumatic stress disorders. On the other hand, men with BPD are more likely than women with BPD to meet criteria for substance use disorders, intermittent explosive disorder, narcissistic personality disorder, and antisocial personality disorder. Further, men with BPD often have more explosive temperaments and exhibit more novelty seeking behaviors than do women with BPD. It is worth noting that although men and women with BPD tend to vary in symptom presentation, research has found that both genders experience equal levels of emotional distress and that equal proportions of men and women with BPD engage in at least one type of self-harm behavior and attempt suicide.
Setting. One’s symptoms and presentation often influence the setting in which they’re treated (and if they’re treated at all). While having an eating or mood disorder will likely lead you to a mental health setting, having an antisocial or explosive presentation may lead you to a correctional setting, where it is less likely that a diagnosis will be given, thus leading to a potential sampling bias.
Socialization. Whether or not we like it, individuals tend to be socialized to view others’ behaviors as more or less acceptable based on that person’s gender. In one study, researchers found that intense anger was believed to be more abnormal for a woman than for a man, suggesting that society may have different thresholds for what is considered normal and abnormal, depending on one’s gender. This can have an impact on treatment utilization (for example, if ‘inappropriate or intense anger’ is chalked up to masculinity rather than as a symptom of a disorder), and may also be responsible for gender bias in diagnosing BPD among clinicians.
Treatment utilization. Research has found distinct gender differences with regard to treatment utilization. While lifetime levels of mental healthcare utilization are high for men and women with BPD, men with BPD are more likely to utilize drug and alcohol rehabilitation services, and less likely to utilize psychotherapy and pharmacotherapy services. This may contribute to different rates of BPD diagnoses given among men and women.
Evidently, men and women with BPD often present and are perceived differently from each other. Differences, too, exist between men with BPD and men with other personality disorders — when compared to men with other personality disorders, men with BPD show more dissociative symptomatology, more frequent use of maladaptive defenses, as well as higher frequencies of childhood sexual abuse, more severe childhood sexual abuse, and increased rates of early separation or loss.
While it’s true that women are more often diagnosed with BPD, and that symptom presentation and patterns differ between genders, research indisputably shows that more men than commonly believed experience BPD, and that rates may actually be equal among men and women. With interest in this topic generating and research evolving, it may not be just Girl, Interrupted for much longer.