Overview of Borderline Personality Disorder
Borderline personality disorder (BPD) is a mental disorder marked by a pattern of
ongoing instability in moods, behavior, self-image, and functioning (APA, 2013). These
experiences often result in impulsive actions and unstable relationships. A person with BPD may
experience intense episodes of anger, depression, and anxiety that may last from only a few
hours to days (NIMH, 2017). BPD has been a diagnosable disorder since 1980 when it was first
included in the third edition of the Diagnostic and Statistical Manual for Mental Disorders (APA,
1987). The U.S. National Institutes of Health (NIH) reports that approximately 5.9% of the U.S.
population has BPD (Grant et al. 2008). The American Psychiatric Association reports a broad
range of prevalence from 1.6% - 5.9% of the U.S. population (APA, 2013). It is most of often
noted that the prevalence rates of BPD in women are much higher than in men, at a ratio of 3:1
(APA, 2013). However, this glaring difference in diagnosis rates has brought about research into
why there appears to be a higher diagnosis rate in women versus men, and there have been
studies conducted in the last ten years that have suggested that the prevalence rates between men
and women are more comparable than often times reported (Grant et al., 2008).
It is important to consider the possible reasons behind the stark difference in rates of
diagnosis of BPD between men and women, as in order to properly and effectively address and
treat BPD as the complex and impactful mental illness it is, there must be a correct diagnosis,
void of bias, error and/or assumption. An exploration of the potential reasons for the differential
diagnosis rates of BPD leads us to examine the methods of sampling in research studies
exploring the demonstration of BPD symptoms, the utilization of treatment modalities, the
potential of clinician bias in assessing for BPD in patients or clients, as well as the potential
differences in how symptoms of BPD are demonstrated in women and men.
Finally, we must consider if there is any evidence of a biological indicator of BPD that
might offer insight into the popularly reported prevalence rates of BPD between men and
women. Could it be that BPD does in fact afflict more women than men, or could women's
socialization within the dominant US cultural framework predispose them to the development of
borderline personality disorder. As Dana Becker (1997) noted in her influential text on BPD and
gender, Through the Looking Glass: Women and Borderline Personality Disorder, gender
inequality between women and men in the United States impacts what is commonly considered
deviant behavior within the constructs of social norms and expectations, and that women, due to
their unequal status in patriarchal structures are vulnerable to being victims of the pathologizing
of otherwise normal expressions of affect .
Diagnosis and Prevalence Rates
It has been established that BPD is more commonly diagnosed in women at a rate of 3:1,
but diagnostic rates do not necessarily capture prevalence rates accurately. It has been suggested
that the prevalence rates of of BPD between men and women are actually more equal (Morey et
al., 2002, Torgersen et al., 2001), or that men have a greater prevalence of BPD than women
(Barzega et al., 2001). Although there are numerous studies to the contrary, it has been
commonly expressed that BPD prevalence is greater in women (Akhtar et al., 1986) , likely due
to the fact the diagnosis of BPD occurs more frequently in women than in men.
Impact of gender on the expression of BPD traits and treatment utilization
Studies examining the prevalence of BPD and BPD related symptoms have noted that the
expression of certain symptoms related to BPD vary depending on gender (Banzhaf et al., 2012,
Sansone., 2011). The features of paranoia and/or dissociation (McCormick et al., 2007), mood
instability (Tadic et al., 2009) and identity instability (Johnson et al., 2003) are more often
expressed in women, whereas men more often expressed the BPD traits of intense and excessive
anger and novelty seeking (Tadic et al., 2009, Sansone., 2011). However, more recent studies
have suggested that women diagnosed with BPD display more hostility and aggression than men
with BPD (Silberschmidt et al., 2015).
Beyond the mere expression of individual traits, it is suggested that women and men vary
regarding the occurrence of particular co-occurring disorders. Substance abuse disorders are
more often diagnosed in the men with BPD, whereas women are more likely to demonstrate
mood (Grant et al., 2008), eating (Tadic et al., 2009), posttraumatic stress (Johnson et al., 2003),
and anxiety disorders (Sansone, 2011). In regard to other personality disorders, women with
BPD are more likely to demonstrate histrionic personality disorder (McCormick et al., 2007),
while men with BPD are more likely to demonstrate narcissistic personality disorder
(Silberschmidt, 2015) and antisocial personality disorder (Sansone, 2011), which is suggested to
demonstrate dominantly in men at a rate of 57% to 26% (Tadic et al., 2009).
The higher rates of substance abuse disorders in men correlates with men with borderline
personality disorder being more likely to utilize treatment services related to substance abuse,
whereas women are more likely to utilize psychotherapy and pharmacotherapy (Goodman et al.,
2010). The differences in treatment utilization leads the way toward exploring how the treatment
settings in which BPD patients seek assistance can influence the figures regarding prevalence of
BPD in men and women. If more men demonstrate antisocial traits and substance abuse issues, it
could be the case that more men with BPD are in substance abuse treatment settings or are
incarcerated, whereas more women with BPD, who more commonly demonstrate disordered
eating, mood instability, PTSD, and/or anxiety may be more greatly represented in inpatient or
outpatient mental health clinic settings. In support of this position it has been reported that in
clinical settings women more often present with symptoms of BPD than do men (Zlotnick et al.,
2002).
Further, borderline personality disorder is reported to be highly represented in
incarcerated populations, at rates greater than its representation in the general public (Sansone,
2009). A study examining the rate of BPD in recently admitted inmates to the Iowa Department
of Corrections found that nearly 30% of those sampled met the criteria for BPD, interestingly,
the rate amongst female inmates in the sample was twice as high (Black et al., 2007).
Consistently, studies of incarcerated populations show prevalence rates of BPD greater than
those demonstrated in the general U.S. population (Sansone, 2009), supporting the notion that
perhaps the differential diagnosis of women versus men is in part related to the likelihood that
more men with BPD are incarcerated and therefore are not considered in studies of BPD amongst
the general U.S. population. However, it is important to note that when gender is considered in
studies of BPD in incarcerated populations, some studies have reported a greater prevalence of
BPD criteria in female inmates compared to males at a rate of 5.3 percent and 11.5 percent
(Burke, 2005).
Although telling regarding the connection between BPD and incarceration, considering
the rate of incarceration is far greater amongst men compared to women, at 93.3% and 6.7%
respectively (FBP, 2017), it is contestable that these results would be suitable to demonstrate a
greater prevalence of BPD in women in general. Rather, they signify a potentially strong
connection between the expression of BPD related symptoms and the likelihood of incarceration.
Research Sampling Bias
The discussion of BPD rates and symptom prevalence in incarcerated populations brings
to light the consideration of sample populations in BPD research. Studies have concluded that in
clinical settings, women were more likely to demonstrate BPD traits, however, a study of clients
utilizing outpatient services for major depression found that men were more likely to meet
criteria for BPD diagnoses (Carter et al., 1999) or that there were no significant gender
differences in the the demonstration of BPD criteria (Golomb et al., 1995).
A 2015 study (Silberschmidt et al.), suggests that women with BPD display more
hostility while men are more likely to demonstrate narcissistic traits along with BPD,
intentionally excluded potential participants that had been treated for substance abuse issues in
the previous 90 days. Although the reasoning behind said exclusion is sound, it does have the
potential to skew results as it has been found that men with BPD are more likely than women to
be treated for substance abuse issues and seek treatment within substance abuse treatment
facilities (Grant et al., 2008). Further, potentially due to the exclusion of participants with
substance abuse treatment in the previous 90 days, Silberschmidt et al., did not find a correlation
between men with BPD and substance abuse issues, a point that is has been strongly made in
multiple studies (Grant et al., 2008, Zanarini et al., 1998) and has supported the notion that BPD
prevalence rates regarding gender demonstration may be skewed due to men with BPD being in
settings that often times are not included in studies.
Further, there does appear to be differences in the types of treatment sought by men and
women, it is possible that women being more likely to seek psychotherapy than men (Goodman
et al., 2010) also means that women are more likely to be disproportionately represented in
studies. Because many BPD studies examining prevalence rates have focused on clinical
samples, the likelihood for sampling bias in these studies is great, as the representation of women
in clinical settings may not mirror that of the general population. To support this position, it has
been found that samples rendered from the general population show no gender difference in the
prevalence of BPD (Busch et al., 2016) and similar findings have been reported in samples from
college aged populations (Morey et al., 2002).
Lastly, the voluntary nature of many studies of BPD presents the possibility that many
people with BPD are simply not partaking in studies and that perhaps those on the lower
functioning end of the spectrum are not considered when generalizing about the prevalence and
scope of BPD (Silberschmidt et al., 2015, p.836).
The Question of Clinician Bias
In the process of diagnosing BPD, and in examining the traits and behaviors attributed to
the disorder, the question of whether or not there is the potential for clinician bias in assessment
and diagnosis arises. Studies have suggested that clinicians have historically had a slight female
bias when diagnosing BPD (Giacalone, 1997). However, this research dates back twenty years
ago and more current research suggests that clinicians do not demonstrate gender bias when
diagnosing BPD (Woodward et al., 2009). Given the research results currently available to
explore this possibility, it seems that contemporarily clinicians are not as likely to hold gendered
bias in regard to the assessment and diagnosis of BPD, but that prevalence rates reported prior to
the beginning of the new millennium were potentially impacted by gender bias. If this is
representative of a larger trend toward less biased BPD assessment and diagnosis, then it may be
the case that moving forward that we will see the reported gender prevalence rates in relation to
BPD become more comparable.
Another point to consider when exploring potential bias in the reported prevalence of
BPD in men and women is the setting in which the assessment and diagnoses are occurring. In a
study examining the settings in which indicators of BPD were prevalently examined and reported
it was found that those working in emergency medical settings were more likely to report
self-harm behavior as the the most significant indicator of BPD, whereas those in mental health
clinical settings more often reported patterns of unstable relationships as the greatest indicator of
BPD (Treloar et al., 2009). Although the results of this study do not explicitly claim an element
gender influence in the prevalence of BPD, it does demonstrate the significance of the setting in
which assessment and diagnosis of BPD occurs. As studies have shown, women and men with
BPD do seek different treatment types, and therefore could be more likely or not to be
represented in certain settings (Goodman et al., 2010), and if in these settings certain BPD traits
are more or less likely to be attributed to the disorder, there then exists a stark possibility for
skewed results when reporting BPD prevalence in various settings.
Implications of bias and future directions
Recent research has suggested biological components of BPD, demonstrated through
brain imaging technology (Foti et al., 2010), which shows a reactive limbic system along with a
reduced capacity for cortical control in people meeting criteria for BPD (Svoboda, 2013).
Although an emerging arena of consideration, the implications of this research are great, as
diagnosing BPD properly has the potential to save lives and reduce the costs of treatment
substantially as those with BPD access appropriate treatment sooner and avoid unnecessary and
inappropriate treatment due to misdiagnosis.
In regard to gender differences in the diagnosis of BPD, it appears as if sampling biases
in research, given that many studies are conducted using clinical settings, has the potential to
greatly skew our insight into the prevalence of BPD in women and men. It would be worthwhile
to expand sampling to better incorporate men into research populations. Further, the potential of
brain imaging technologies to identify predisposition to BPD could in time altogether eliminate
the greatest impacts of sampling and clinician bias, given men and women have equal access to
the medical technologies able to identify such predispositions.
Ultimately, assessing and diagnosing borderline personality disorder accurately is of the
utmost importance when considering the highly detrimental impact of BPD on the lives of those
who struggle with it. According to the National Institute of Mental Health, the suicide rate for
those with BPD is 400 times the national average, making the proper diagnosis and treatment of
BPD a literal matter of life and death. Given the severity of BPD and the consequences of
undiagnosed and/or untreated BPD, serious consideration must be given to research that explores
BPD void of bias and assumption.
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