March Madness

A lot of questions have been coming my way about the problem of gender bias in borderline personality disorder diagnoses, and in honor of today's kick-off to Women's History Month, I offer this blog post not as a response but as an invitation to begin a collaborative inquiry.  Let's figure it out together.  Two components of gender bias stand out immediately: (1) the disproportionate diagnosis of women as borderlines, and (2) the overlap between borderline personality traits and traditionally 'feminine' traits.  A number of important feminists have worked on the question of how psychiatric labels have been used to subjugate women (Phyllis Chesler, Jane Ussher, Jean Baker Miller, to name three out of a throng of feminist scholars).  A smaller group of feminist disability theorists have pushed back against this feminist renunciation of psychiatric labels, advocating for the labels as 'enabling fictions' that provide us with a useful way of understanding and describing psychological distress, not to mention an avenue of access to social and medical support (mainly I'm thinking here of Andrea Nicki's article, "The Abused Mind," but there are others working along similar lines).  

In the specific context of borderline personality disorder, Dana Becker has advanced a strong feminist critique of BPD, a condition she says is "arguably the most pejorative diagnosis of our time," so I'm pasting a segment of her work below (pulled from the website for the Association for Women in Psychology).

Let the conversation begin!  

Is borderline personality disorder a big ol' sexist ruse?  Does it have any liberatory dimensions worth celebrating? 

Borderline Personality Disorder:  The Disparagement of Women through Diagnosis

Dana Becker, Ph.D.  Professor, Bryn Mawr Graduate School of Social Work and Social Research

Borderline Personality Disorder (BPD) is currently defined in the Diagnostic Statistical Manual of Mental Disorders as a persistent pattern of instability (both personal and interpersonal) and impulsivity. Its symptoms range from self-damaging and suicidal behavior to intense mood reactivity, feelings of emptiness, and problems controlling anger.  It entered the DSM in the 1980 edition and is currently the most frequently diagnosed personality disorder.

The primary characteristic of any personality disorder is said to be its stability over time, but as described in the current DSM-IV-TR, BPD is characterized by instability—of identity, of mood, of behavior — and there are well over 100 ways to combine its symptoms that qualify a person for the BPD diagnosis. Given the diversity of its symptomatic picture, many, even in the psychiatric profession, have had difficulty conceiving of BPD as a single disorder. According to the DSM-IV-TR, about 75% of people diagnosed with Borderline Personality Disorder are women.  This was not always the case.  BPD criteria have been altered appreciably over the past fifty years to include more and more symptoms related to emotion, accounting at least in part for the sex bias inherent in the diagnosis.  Many researchers have challenged the validity of BPD, some concluding that BPD has become a catch-all label given to people, especially women, who experience acute sadness, emptiness, and emotional reactivity (particularly in the form of rage). The BPD diagnosis overlaps with other diagnoses such as Histrionic and Dependent Personality Disorders, which have been assailed for pathologizing behavior (e.g., dependency, seductiveness) that many women have been socialized to exhibit. 

Some women who have been diagnosed with BPD have histories of psychological maltreatment, neglect, and/or childhood sexual or physical abuse, and they may have difficulty expressing anger “appropriately.”  The ways in which “borderline” women express their pain has occasioned a vast clinical literature on how to treat “borderlines” and how to manage the strong emotions they may arouse in their therapists.  So-called borderline women are often described as angry and manipulative, when in fact they often act out because they do not trust that others will meet their needs if they express them straightforwardly.

The BPD diagnosis has been used in court to institutionalize and/or medicate women involuntarily, deny them custody of their children, and have their parental rights terminated.  Women diagnosed as having BPD have also frequently been discredited as witnesses in court cases involving rape or sexual abuse. 

Categorizing a particular set of disparate symptoms we now call “borderline” as a personality disorder encourages clinicians to focus on a particular style of coping learned under adverse circumstances rather than on the forms of abuse and emotional invalidation that originally made that style of coping necessary.  The association between women and what is arguably the most pejorative diagnosis of our time can create fear and avoidance, if not frank hostility, on the part of students of psychotherapy and practicing professionals toward a population of extremely vulnerable women.

SOURCES 

Becker, D.  (1997).  Through the looking glass:  Women and borderline personality
disorder.  Boulder:  Westview Press.

________.  (2000).  When she was bad: Borderline personality disorder  in a
posttraumatic age.  American Journal of Orthopsychiatry, 70 (4), 422-432.

________.  (2001).  Diagnosis of psychological disorders:  DSM and gender. 
In J. Worrell (Ed.), The encyclopedia of gender, Vol. 1 (pp. 333-343).  San Diego: 
Academic Press. 

Becker, D., & Lamb, S.  (1994).  Sex bias in the diagnosis of borderline personality
disorder and posttraumatic stress disorder.  Professional Psychology:  Research and
Practice, 25,  55-61.

Brown, L. S. & Ballou, M.  (1994).  Personality and psychopathology.  New York:  Guilford.

Herman, J. L., Perry, J. C., van der Kolk, B. A.  (1989).  Childhood trauma in borderline personality disorder.  American Journal of Psychiatry, 146 (4), 460-465.

Nurnberg, H. G., Raskin, M., Levine, P. E., Pollack, S., Siegel, O., & Prince, R.  (1991).  The comorbidity of borderline personality disorder and other DSM-III-R Axis II personality disorders.  American Journal of Psychiatry, 148 (10), 1371-1377.

Ogata, S. N., Silk, K. R., Goodrich, S., Lohr, N. E., Westen, D., & Hill, E. M.  (1990). Childhood sexual and physical abuse in adult patients with borderline personality disorder.  American Journal of Psychiatry, 147 (8), 1008-1013.

Shaw, C., & Proctor, G.  (2005).  Women at the margins:  A critique of the diagnosis of borderline personality disorder.  Feminism & Psychology, 15 (4), 483-490.