The Link Between Sexism and Borderline Personality Disorder in Men

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I felt prompted to write this post so as to inform others about the link between sexism and mental illness. A mental illness that is primarily linked to women is Borderline Personality Disorder. As a newbie/learning clinician and a feminist I find it important to speak to this issue.

Borderline Personality Disorder does exist in men, however, most clinicians will tell you that the majority of individuals with BPD are women. These are indeed the statistics. My argument is that there are more men with BPD than is often realized and this is largely due to patriarchy.

Let's start with the basics.

What is Borderline Personality Disorder?

According to the DSM-IV-TR (Diagnostic Statistics Manual - 4th edition)

It is a  pervasive pattern of instability of interpersonal relationships, self image and affects and marked impulsivity beginning in early adulthood and present in a variety of context, as indicated by five or more of the following.

  1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

  2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 

  3. identity disturbance: markedly and persistently unstable self-image or sense of self. 

  4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5

  5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 

  6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 

  7. chronic feelings of emptiness 

  8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 

  9. transient, stress-related paranoid ideation or severe dissociative symptoms

So, what does this mean in plain speak? Well, it's a bit more complicated than a one liner description. I will say right off, that in my experience most clinicians do not like working with individuals with BPD. I've worked in outpatient clinics and I currently work in a psychiatric hospital. I can tell you that many a doctor will roll their eyes when they realize they have a patient with BPD on the ward.

As a psychiatric social worker I've not had experience providing therapy with someone with BPD. So, yes my knowledge is limited, however, I do have strong opinions about the link between sexism and personality disorders. I will explore this a bit later in this post.

There is often a push-pull dynamic within BPD individuals. "I'll abandon you before you can abandon me". Sometimes the abandonment is real and sometimes it is imagined. Those with BPD can often be manipulative, demanding, intrusive and impulsive.

I recall working in an outpatient clinic with a co-worker who was working with a patient with BPD. This patient demanded that my co-worker be ready for their weekly appointment on the dot and not even a minute later. Otherwise this person felt devalued, abandoned, and unwanted. In this situation a person with BPD may reject a person whom they favored with explosive anger.  "I want you, I want you, I need you, I hate you, I hate you, go away".

It's a delicate dance for clinicians. I've worked towards putting up strong boundaries with patients as well as hearing their concerns, showing genuine empathy, and working with them to meet their goals. It's a lot of work and I often witness clinicians furrow their brows with frustration and neglect to whole-heartedly focus on treatment.

Origins of BPD

Where does BPD come from? Many of us are still scratching our heads. While genetics may be partly responsible; environmental considerations are most prevalent. It is thought that those who have experienced trauma at a young age and break of trust, develop a skewed view of what constitutes real abandonment when they're older.

This isn't always the case. Healthily nurtured children can also develop BPD. Sounds like a crap shoot but researchers continue to invest in the search for concrete answers. But really; how concrete is anything? Love/Hate; Healthy/Ill; Up/Down? 

Co-Occuring Disorders

BPD rarely manifests on its own. Other disorders are often tagged with it. According to NAMI (National Alliance on Mental Illness) some statistics are as follows.

Co-morbidity with other disorders:

Major Depressive Disorder                                                --  60 percent

Dysthymia  (chronic, moderate to mild depression)          --  70 percent

Eating Disorders                                                               --  25 percent

Substance Abuse                                                               -- 35 percent

Bipolar Disorder                                                                -- 15 percent

Antisocial Personality Disorder                                          -- 25 percent

Narcissistic Personality Disorder                                        -- 25 percent

Why Men Rarely Seek Help

So, here we go. In the research I've reviewed back during my days in grad school; I found that the literature reflected stigma against a sole gender. It is women who are supposedly most often suffering from BPD. This may be false. I cannot say with all confidence that it is mostly women, mostly men, or equal numbers between men and women who experience BPD. What I can say in earnest is that there is often a bias when it comes to diagnosis.

I would say that the symptoms a woman experiences are identical to what a man experiences. What might be different is the way in which men and women express themselves and they way they are received in a sexist society.

Men with BPD may express anger, hostility, arrogance and even violence. Some of these modes of expression are considered admirable, acceptable or a quality of strength. When women express anger it is often interpreted as irrational, too emotional, or "crazy". Some women are referred to as "bitches" or are considered to be lacking intelligence in some way.

Men and Treatment

It is extremely unfortunate that men often do not receive the treatment they need. Again, I attribute this to patriarchy. We already know that a man showing emotion is not popular in most environments. Because of this, men rarely seek help for any type of mental illness. BPD is a diagnosis that envelops one's entire personality and functioning. As you can imagine, this results in a huge sense of vulnerability and adds to the sense of abandonment that those with BPD already feel.

I do know that because men do not seek treatment as often, it is difficult to research men with BPD. This is how deep and dangerous patriarchy runs. It ruins lives and perpetuates suffering. Just another example as to how men gain and suffer from sexism. Sexism is not just a woman's issue.

Healing and Recovery

Personality disorders are hard to treat. A co-occuring disorder such as depression, can be treated with medication and of course therapy. It is extremely important for those with BPD to undergo therapy, however, medication cannot erase a personality disorder.

BPD, anti-social disorders, narcissistic disorders, are thought to remain with a person until the end of their days. What a dooming thought. Once a borderline, forever a borderline?

If you've noticed, up until I wrote the above question, I've taken care to identify those with this illness as people who experience BPD rather than refer to them as BPD individuals. This is because I have always believed that a person is not their illness. It is not what encapsulates them.

If you noticed I stated that I have taken care to identify those will illness correctly. By "taking care", I admit that I too am guilty of placing mentally individuals in a box. I continue to work on the language I use so as not to perpetuate stigma that does not assist those suffering in any way.

I can't tell you how irked I am when a person refers to a patient as "a Schizophrenic", rather than stating that they have Schizophrenia or experience Schizophrenia. So many clinicians that I have worked with do not rebel against stigma and continue to refer to a person as the illness they experience or even refer to them as "crazy" or "nuts". Makes me cringe and breaks my heart.

But what about a person with a personality disorder? Personality disorders affect one's entire personality. So are individuals with BPD truly individuals with BPD or are they truly "borderlines"?

I say that anyone who is capable of changing, modifying, improving, stabilizing; need not label their identity.

Let's look at some tools of hope.

DBT

DBT (dialectical behavioral therapy) and CBT (cognitive behavioral therapy) are modalities that are often utilized to treat those with BPD.

DBT in particular is geared towards those with BPD. According to Psych Central, there are four distinct modes of treatment in DBT.

1. Individual therapy
2. Group skills training
3. Telephone contact
4. Therapist consultation

1. Individual Therapy

The individual therapist is the primary therapist. The main work of therapy is carried out in the individual therapy sessions. The structure of individual therapy and some of the strategies used will be described shortly. The characteristics of the therapeutic alliance have already been described.

2. Telephone Contact

Between sessions the patient should be offered telephone contact with the therapist, including out of hours telephone contact. This tends to be an aspect of DBT balked at by many prospective therapists. However, each therapist has the right to set clear limits on such contact and the purpose of telephone contact is also quite clearly defined. In particular, telephone contact is not for the purpose of psychotherapy. Rather it is to give the patient help and support in applying the skills that she is learning to her real life situation between sessions and to help her find ways of avoiding self-injury. 

Calls are also accepted for the purpose of relationship repair where the patient feels that she has damaged her relationship with her therapist and wants to put this right before the next session. Calls after the patient has injured herself are not acceptable and, after ensuring her immediate safety, no further calls are allowed for the next twenty four hours. This is to avoid reinforcing self-injury.

3. Skills Training

Skills training is usually carried out in a group context, ideally by someone other that the individual therapist. In the skills training groups patients are taught skills considered relevant to the particular problems experienced by people with borderline personality disorder. There are four modules focusing in turn on four groups of skills:

1. Core mindfulness skills.
2. Interpersonal effectiveness skills.
3. Emotion modulation skills.
4. Distress tolerance skills.

The core mindfulness skills are derived from certain techniques of Buddhist meditation, although they are essentially psychological techniques and no religious allegiance is involved in their application. Essentially they are techniques to enable one to become more clearly aware of the contents of experience and to develop the ability to stay with that experience in the present moment. 

The interpersonal effectiveness skills which are taught focus on effective ways of achieving one’s objectives with other people: to ask for what one wants effectively, to say no and have it taken seriously, to maintain relationships and to maintain self-esteem in interactions with other people. 

Emotion modulation skills are ways of changing distressing emotional states and distress tolerance skills include techniques for putting up with these emotional states if they can not be changed for the time being. 

The skills are too many and varied to be described here in detail. They are fully described in a teaching format in the DBT skills training manual (Linehan, 1993b). 

4. Therapist Consultation Groups

The therapists receive DBT from each other at the regular therapist consultation groups and, as already mentioned, this is regarded as an essential aspect of therapy. The members of the group are required to keep each other in the DBT mode and (among other things) are required to give a formal undertaking to remain dialectical in their interaction with each other, to avoid any pejorative descriptions of patient or therapist behavior, to respect therapists’ individual limits and generally are expected to treat each other at least as well as they treat their patients. Part of the session may be used for ongoing training purposes. 

Stages of Dialectical Therapy 

Patients with BPD present multiple problems and this can pose problems for the therapist in deciding what to focus on and when. This problem is directly addressed in DBT. The course of therapy over time is organised into a number of stages and structured in terms of hierarchies of targets at each stage. 

The pre-treatment stage focuses on assessment, commitment and orientation to therapy.

Stage 1 focuses on suicidal behaviors, therapy interfering behaviors and behaviors that interfere with the quality of life, together with developing the necessary skills to resolve these problems. 

Stage 2 deals with post-traumatic stress related problems (PTSD) 

Stage 3 focuses on self-esteem and individual treatment goals.

The targeted behaviors of each stage are brought under control before moving on to the next phase. In particular post-traumatic stress related problems such as those related to childhood sexual abuse are not dealt with directly until stage 1 has been successfully completed. To do so would risk an increase in serious self injury. Problems of this type (flashbacks for instance) emerging whilst the patient is still in stages 1 or 2 are dealt with using ‘distress tolerance’ techniques. The treatment of PTSD in stage 2 involves exposure to memories of the past trauma. 

Therapy at each stage is focused on the specific targets for that stage which are arranged in a definite hierarchy of relative importance. The hierarchy of targets varies between the different modes of therapy but it is essential for therapists working in each mode to be clear what the targets are. An overall goal in every mode of therapy is to increase dialectical thinking. 

The hierarchy of targets in individual therapy for example is as follows:

1. Decreasing suicidal behaviors.
2. Decreasing therapy interfering behaviors.
3. Decreasing behaviors that interfere with the quality of life.
4. Increasing behavioral skills.
5. Decreasing behaviors related to post-traumatic stress.
6. Improving self esteem.
7. Individual targets negotiated with the patient.

In any individual session these targets must be dealt with in that order. In particular, any incident of self harm that may have occurred since the last session must be dealt with first and the therapist must not allow him or herself to be distracted from this goal. 

The importance given to therapy interfering behaviors is a particular characteristic of DBT and reflects the difficulty of working with these patients. It is second only to suicidal behaviors in importance. These are any behaviors by the patient or therapist that interfere in any way with the proper conduct of therapy and risk preventing the patient from getting the help she needs. They include, for example, failure to attend sessions reliably, failure to keep to contracted agreements, or behaviors that overstep therapist limits. 

Behaviors that interfere with the quality of life are such things as drug or alcohol abuse, sexual promiscuity, high risk behavior and the like. What is or is not a quality of life interfering behavior may be a matter for negotiation between patient and therapist. 

The patient is required to record instances of targeted behaviors on the weekly diary cards. Failure to do so is regarded as therapy interfering behavior.

What Now? 

What can we do to reverse stigma? What can we do to reverse the damage of patriarchy? We need to work as a collective. There are plenty of organizations that work towards reducing stigma. And while they do noble work, I have yet to run into organizations that work towards smashing sexism that is clearly a barrier.

Hopefully this long-ong post has reached you in some way. Pass it on.

Resources

NEABPD (National Education Aliance for Boderline Personality Disorder) 

NAMI National Alliance on Mental Illness 

BPD Central - Borderline Personality Disorder Information and Support

NIMH - National Institute of Mental Health