The term "borderline," used to describe Borderline Personality Disorder (BPD), has entered the mainstream these days with television movie-of-the-weeks sensationalizing "borderlines" and making them appear like dangerous exotic animals to stare at, fear, and condemn. Television producers love many of the serious mental disorders because producers are always looking to fill the screen with as much dramatic action as possible. If you know at least a little bit about BDP, you know that some of its symptoms include extreme behavior, which is often life-threatening. The problem? Borderlines are real people with emotional injuries. We shouldn't turn them into dysfunctional caricatures.
For years, I believe we misunderstood BPD, particularly with regard to gender differences in BDP. Though the field historically believed that women suffer from BPD as much as three times the frequency of men, recent research by Grant and colleagues (2008) suggests that men and women show a similar prevalence for the disorder (5.6% among men, 6.2% among women). The researchers of the recent study, however, also indicate that the expression of the disorder manifests differently in men and women.
Anecdotally, in my work on inpatient psychiatric units, I have found that the are differences in the way borderline men and borderline women approach the world and those around them. More importantly, research confirms the differences. For example, Zlotnick and colleagues (2002) found gender differences with regard to the type of impulsive behavior in which Borderline men and women engage. They found that men presented more substance abuse, antisocial features, and intermittent explosive disorder, while women presented more eating disorders.
When it comes to self-harm behavior, I was taught in graduate school that women are "cutters," another essentially derogatory, judgment-prone term, while Borderline men don't tend to cause physical harm to themselves. Yet Oumaya and colleagues (2008) suggest that men and women actually engage in a similar rate of self-harm behavior, which includes cutting, brusing, head-banging, and biting.
Given the likelihood that Borderline men and women are similar in some ways and different in others, the overall results beg the question: Do borderline men and women differ in the severity of their borderline personality? That's no easy question to answer, but Zlotnick et al. (2002) found that both men and women presented for treatment with equal levels of emotional distress.
When it comes to seeking out mental health treatment, both men and women seek out mental health services at high rates throughout the lifetime. However, Goodman and colleagues found that men with BPD are more likely than women to seek out substance abuse rehabilitation services but not as likely to seek out pharmacotherapy and psychotherapy services.
Finally, as we consider gender differences, I must address the fact that some readers may have some questions about what is happening to the BPD diagnosis given the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). It's worth noting because the categorization for BPD almost changed. According to Stetka and Correll's "A Guide to the DSM-V" (2013), in the field trials conducted in preparation for the new DSM revision, BPD was the only personality disorder that had good interrater reliability. Meaning? More than one therapist would assess the same person and both agree that the symptoms are the same, and were also consistent with the criteria as outlined by the model for The BPD diagnosis in the last DSM. In the end, the same personality disorder models were kept for DSM -V that were included in the DSM-IV, though Section 3 of the new manual includes discussion of a new hybrid model of diagnosing all the personality disorders.
While the current BDP classification may not be affected much by gender differences, I do believe that the next Work Group should seriously evaluate the prevalence rates of BPD in women and men, in addition to specific ways in which the expression of the disorder may be express itself in women and men. Until then, we can all do the same: Keep reading and stay abreast of good new research.
Goodman M, Patil U, Steffel L, et al. Treatment utilization by gender in patients with borderline personality disorder. J Psychiatr Pract. 2010;16:155–163.
Grant BF, Chou SP, Goldstein RB, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry.2008;69:533–545.
Oumaya M, Friedman S, Pham A, et al. Borderline personality disorder, self-mutilation, and suicide: literature review. Encephale. 2008;34:452–458.
Stetka, B, Correll, C. A Guide to the DSM-V. Medscape Psychiatry, May 21, 2013.
Zlotnick C, Rothschild L, Zimmerman M. The role of gender in the clinical presentation of patients with borderline personality disorder. J Pers Disord. 2002;16:277–282.