Gender Issues and Borderline Personality Disorder: Why do Females

Dominate the Diagnosis? Debra Simmons

There are significantly more females with the diagnosis of borderline personality disorder than males. This article explores the developmental factors that place females at a greater risk to develop the disorder. Societal expectations that increase the emerging of borderline symptoms are also discussed. Gender dif- ferences of “normal” behavior that effect the assigning of the diagnosis are explained. The theory that borderline personality disorder has become the “vi- rus” of psychiatry is presented. Copyright 0 1992 by W.B. Saunders Company

T HEY’RE COMING OUT of the woodwork!” is a phrase often heard from mental health

professionals regarding the vast numbers of fe- males diagnosed with borderline personality disor- der (BPD). Gunderson and Zanarini (1987) esti- mate that 15% to 25% of both inpatient and outpatient clients have a diagnosis of BPD and that two thirds of these are female. In the clinical set- ting, these estimates frequently appear modest be- cause the borderline patient can become an over- whelming presence.

The person with BPD is described by the Amer- ican Psychiatric Association (1987) as having “a pervasive pattern of instability of mood, interper- sonal relationships, and self image. . . . ” Smith and Lego (1984) describe the person with BPD as being impulsive, destructive, manipulative, clingy, hostile, controlling, unstable, and sexually promiscuous.

Although there is much information in the liter- ature about the origin, diagnosis, treatment, and clinical issues of BPD, there is no information con- cerning why there are more females with the diag- nosis. Four theories for this phenomenon are pre- sented and explored: (1) the differences in parenting of males and females, (2) gender differ- ences of “normal” behavior, (3) the stresses of con- temporary females, and (4) the borderline diagnosis as the negative catch-all of psychiatric diagnoses.

DEVELOPMENTAL ORIGIN OF BPD

Masterson ( 1976) writes that BPD originates during the rapprochement phase that occurs be- tween 16 and 24 months in Mahler, Pine, and Bergman’s (1975) separation-individuation pro- cess. The child shows both “shadowing and dart- ing away,” indicating both the wish for reunion with the mother and the fear of re-engulfment. The healthy caregiver will allow these conflicting be- haviors and be encouraging of attempts at indepen- dence yet remain available for support and nurtur- ing as needed. The roots of BPD become established when the caregiver cannot tolerate this paradoxical behavior and restricts the process by rewarding dependent behavior and punishing inde- pendent behavior. In this way the child comes to be rewarded for clinging behavior and punished for autonomous behavior. Moves toward autonomy lead to what Masterson (1976) calls abandonment depression, that is, the fear the child is alone for- ever, cut off from the mother.

From the Graduate Program in Psychiatric Nursing, Kent State University, Kent OH.

Address reprint requests to Debra Simmons, B.S.N., R.N., 451 Howe Rd., Kent, OH 44240.

Copyright 0 1992 by W.B. Saunders Company 0883-9417/92/ofx4-cOo3$3.00/0

Archives of Psychiatric Nursing, Vol. VI, No. 4 (August), 1992: pp. 219-223 219

220 DEBRA SIMMONS

WHY ARE THERE MORE FEMALES WITH BPD?

Differences in Parenting of Males and Females

Benjamin (1986) discusses the role of the father in childhood and his contribution to the female adult’s search for the “ideal love.” The fathering role can also be related to the development of BPD in the female child. During rapprochement, aware- ness of gender identity emerges. The child needs the father for recognition, not just for gratification or as a supplier of needs. Fathers are needed as an “escape route” for the girl to appropriately sepa- rate from the mother. Girls are more aware than boys of gender differences during the rap- prochment period and have more difficulty sepa- rating from their mothers than boys do. Fathers bond more intensely with boys, creating greater attachment and identification with sons as tod- dlers. Fathers are frequently unable to identify with daughters as they do with sons (Benjamin, 1986). Miller (1976) writes that on the individual level, children grow only via engagement with people very different from themselves. Because the girl needs to have a person highly different from the mother to recognize and validate her, this is logically the father. If the father is unavailable or uninvolved, this leads to poor progression through the separation-individuation process for the fe- male. Because this process is where BPD pathol- ogy originates, this would indicate that girls are at a greater risk to develop the disorder than boys.

This lack of recognition from the father can lead to the submissive or unstable relationships fre- quently seen in adults with BPD. Benjamin (1986) believes this submission is an attempt to recon- struct the relationship with the father to gain rec- ognition and the opportunity to separate and indi- viduate again.

Gilligan (1982) explains that for boys, separa- tion from the mother is essential for the develop- ment of masculinity, while separation from the mother is not essential for the development of fem- ininity in girls. Because femininity is obtained through attachment, females are threatened by sep- aration and tend to have problems with individua- tion. This helps explain the problems surrounding abandonment and the clinginess and manipulation seen in the borderline adult. The female has been conditioned to achieve her identity through attach- ment and dependency and fears loss of this identity

if she is forced to separate or individuate from any significant other.

It is well documented that parents, as well as members of American society in general, react dif- ferently to and have different expectations of boys and girls. This difference extends through child- hood and into adulthood. Miller (1976) writes that females are encouraged to concentrate on the needs of others and to ignore their own needs. Women are expected not to consider their needs or desires, but to take care of men. This teaches women to “transfer” their needs and to see their needs as identical to those of men or children (Miller, 1976). Through observation, it appears that women are encouraged to be submissive and de- pendent yet responsible and controlling at the same time. This keeps the woman from developing to her fullest capacity while she is frequently given full responsibility and control, especially of the family. A vicious cycle develops, with her own daughter sensing the paradox of needing to sepa- rate, being dominated by a submissive mother with no father readily available. Fearing individuation, she has no healthy role model for this task.

Miller (1976) further substantiates this process by saying that males are encouraged to be active and rational, while females are encouraged to be involved with emotions and feelings. Yet women are criticized or considered mentally ill when they do this (Chesler, 1972).

Franks and Rothblum (1983) discuss at length the prevalence of agoraphobia in women and the theory that this is conditioned early in life by over- protectiveness and then continued into adulthood with the expectation that women perform typical homebound duties. It has been noted that it is not uncommon for persons with BPD to have some agoraphobic tendencies or to actually have both diagnoses. Some terms used to describe the ago- raphobic person are passive, anxious, dependent, fearful, and nonassertive (Franks 8z Rothblum, 1983). These terms can also describe the person with BPD who shows the characteristics of “af- fective instability” and “frantic efforts to avoid real or imagined abandonment” (American Psy- chiatric Association, 1987). Franks and Rothblum (1983) write that “lack of encouragement in ex- ploring one’s environment” is a classic symptom of agoraphobia and is perhaps “part of the social- ization of females and is learned very early in life” (p. 121). This is precisely what occurs in the rap-

GENDER AND BORDERLINE PERSONALITY DISORDER 221

prochement period to prohibit normal separation- individuation, leading to the development of BPD.

It is estimated that 85% of all diagnosed agora- phobics are female (Franks & Rothblum, 1983). The comparison between agoraphobia and BPD in- dicates that both are predominantly disorders of females, both can share similar symptoms, and most importantly, both appear to develop at the same time during rapprochement as a result of the same restriction on independence. This would fur- ther support the theory that females are at a greater risk to develop BPD because of the traditional dif- ferences in parenting of boys and girls.

Gender Differences of Normal Behavior

Obviously, people are different and will fre- quently behave differently in the same situation. Nevertheless, there are conflicting ideas about what is normal or acceptable behavior for males and females in our society. This could become a factor when making an Axis II diagnosis, espe- cially in diagnosing BPD. Some behaviors listed as abnormal that lead to a BPD diagnosis are exces- sive anger, argumentativeness, and sexual promis- cuity (Smith & Lego, 1984). These behaviors are frequently seen as acceptable, expected, and even humorous in males.

There are conflicting opinions in the literature regarding differing behavioral norms depending on gender. It does appear that the majority of studies support the theory that there are different expecta- tions of both genders. Henry and Cohen’s (1983) study rating the presence of borderline symptoms concluded that borderline behavior is more congru- ent with the male sex role and less tolerable, or more pathological, in women. It is rare that a man will receive a BPD diagnosis if he is sexually pro- miscuous or argumentative or shows excessive an- ger. A male will usually receive a diagnosis of antisocial personality disorder, whereas a female will receive the BPD diagnosis for the same symp- toms.

Gunderson and Zanarini (1987) report that an estimated 25% or more of antisocial and borderline personality disorders meet the criteria for both di- agnoses. “Sex bias probably prejudices clinicians to overlook the antisocial features of female pa- tients and the dependent, needy (borderline) fea- tures of male patients” (p. 7).

Gilligan ( 1982) writes that measurement of nor- mal behavior has been based on men’s interpreta-

tion of research data taken from studies of males. McClelland ( 1975) states that therapists “have tended to regard male behavior as the ‘norm’ and female behavior as some kind of deviation from that norm” (p. 81).

Kaplan (1983), in a controversial article assert- ing the Diagnostic & Statistical Manual, 3rd Edi- tion (DSM III) is gender biased, states that men have an assumption about what constitutes normal behavior that is evident in the DSM III. She be- lieves that healthy women sometimes receive an Axis II diagnosis because of gender bias in the characteristics presented in the DSM III.

Broverman, Broverman, and Clarkson (1970) found in their study that clinicians gave different descriptions of the healthy adult, the healthy male, and the healthy female. Descriptions of the healthy adult (a person of nonspecified gender) and the healthy male were similar, but a healthy female was described as submissive, dependent, nonad- venturous, noncompetitive, less aggressive, and less objective. She was also thought to be more excitable and emotional than a healthy adult.

Chesler (1972) believes that females are often seen as “sick” whether they accept or reject the typical female role. They can receive an Axis 1 diagnosis if they act out the role of being de- pressed, incompetent, frigid, or anxious. Yet they may receive an Axis II diagnosis if they reject the female role by being hostile, successful, or sexu- ally active.

The observations of Kaplan (1983), Broverman et al. (1970), and Chesler ( 1972) occurred before the diagnosis of BPD came into existence. Al- though some women have progressed beyond these stereotypes, many are still fulfilling these expec- tations, and the observations are quite relevant. It appears women are considered unstable if they show any behavior such as excitement, depression, competitiveness, or nonsubmissiveness. Because the characteristics of the BPD diagnosis leave much room for varying behaviors, the logical di- agnosis is that of BPD. More men would likely receive the BPD diagnosis if the gender bias of normal behavior could be alleviated by the clini- cian.

The Stresses of Contemporary Females

Those women who do not portray the typical images of stay-at-home housewives and mothers are being met with a new set of stressors uncom-

222 DEBRA SIMMONS

mon to women of past decades. There are in- creased responsibilities and expectations to be wife, mother, career person, student, and manager of the financial and physical aspects of the house- hold (Hochschild, 1989). With divorce becoming more common and the extended family farther away, today’s woman is frequently a single parent with few support systems. Miller (1976) writes of women being expected to do the lesser job of help- ing others to develop, yet ‘ ‘ . . women have had to do this major task without the supports that a culture would give to a task it valued” (p. 40). It appears that men’s expected roles of becoming professionals or the breadwinners of the family have remained stable over the years. Expectations for women have increased, with no alleviation of the previous responsibilities. Although BPD orig- inates in the rapprochement period of childhood, these increased stressors on adult women create a setting for the BPD symptoms to surface and to be reinforced more now than in women of the past.

Borderline Diagnosis as the Negative Catch-All of Psychiatry

It is my opinion that BPD has become the virus of psychiatry. In the medical field, a virus is di- agnosed if a patient has a group of common, vague symptoms. The patient may also receive the viral diagnosis if the physician is unsure of the cause of the symptoms. The female psychiatric patient is assigned the diagnosis of BPD if she has vague, general symptoms indicating instability of any kind. She may also receive the BPD diagnosis if the clinician is uncertain of the pathology or expe- riences negative feelings while interacting with her.

Angus and Manziali (1988) conducted a com- parison between three tools used to diagnose BPD: (1) the Diagnostic Interview for Borderline Pa- tients, (2) the Personality Disorder Questionnaire, and (3) the Personality Disorder Examination. The study resulted in poor concordance among the tools and poor correspondence to the guidelines used in the DSM Ill. This finding indicates that diagnosis of BPD is difficult and should be done carefully after in-depth assessments and histories are completed and other diagnoses are considered. It has been my experience that a diagnosis of BPD is frequently assigned immediately and that no tools are used to make this diagnosis.

It has been noted during clinical experience that

male therapists tend to use the BPD diagnosis more frequently and readily than do female therapists. If female patients are not blatantly psychotic or deeply depressed, the diagnosis will be BPD. Bernstein and LeComte (1982) state that L‘ , . . there is some evidence that on mental health judgments, male therapists or counselors tend to stereotype to a greater degree than do women” (p. 744). Their study found that female clinicians are more empathetic toward clients of both sexes than are male clinicians. The study also indicated that male therapists expect to be more directive and anticipate greater client needs. These results indi- cate a need for clinicians to be aware of their own negative reactions to clients or their own need to be controlling.

Zanarini, Gunderson, Frankenburg, and Chauncey’s (1990) study found that other Axis II diagnoses and BPD share many clinical features. The results were considered important “. . . given the propensity of many health professionals to la- bel almost all effectively intense, impulsive, and interpersonally difficult patients as BPD” (p. 166).

The BPD diagnosis becomes a label for those receiving it, and once it is assigned it is difficult to change or to escape its implications. The diagnosis has a negative connotation that is difficult to ig- nore. As indicated by Gallop, Lancee, and Garfinkel (1989), borderline patients may receive a lower level of care than other patients because of this negative label. This study found nurses to be belittling and less empathetic toward borderline patients, “The diagnosis of borderline personality disorder may have become a negative stereotypic category that precedes the patient and sets the tone for subsequent interaction” (p. 8 19).

It seems apparent that the BPD diagnosis is er- roneously assigned at times because of clinicians’ lack of awareness of their own transference and their lack of meticulous assessments. It is the eth- ical responsibility of each clinician to take every precaution to prevent this erroneous diagnosing and subsequent lifelong labeling of patients who may in actuality meet criteria for a less stigmatiz- ing diagnosis.

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