No Man's land Gender bias and social constructivism in the diagnosis of borderline personality disorder.pdf

Taylor & Francis Inc.

ISSN: 0161-2840 print / 1096-4673 online

DOI: 10.1080/01612840500312753

NO MAN’S LAND: GENDER BIAS AND SOCIAL

CONSTRUCTIVISM IN THE DIAGNOSIS OF

BORDERLINE PERSONALITY DISORDER

Pamela Bjorklund, Ph.C., RN, CS, PMHNP-BC

University of Minnesota, Minneapolis, Minnesota, USA and

The College of St. Scholastica, Duluth, Minnesota, USA

The literature on borderline personality disorder (BPD),

including its epidemiology, biology, phenomenology, causes,

correlates, consequences, costs, treatments, and outcomes is

vast. Thousands of articles and books have been published.

Because the true prevalence of BPD by sex (gender) in the

general population is still unknown, the important question

of why women, rather than men, are more frequently

diagnosed with BPD remains largely unanswered—despite

current evidence for the origin of personality disorder in

genetics and neurobiology, and despite recent suggestions

that biased sampling is the most likely explanation for

gender bias in the diagnosis of BPD. This paper reviews

selected literature on (a) the epidemiology of BPD,

(b) gender bias in the diagnosis of BPD, and (c) the social

construction of diagnosis, particularly the diagnostic entity

labeled “Borderline Personality Disorder.” It attempts a

synthesis of diverse, multidisciplinary literature to address

the question of why women outnumber men by a ratio of 3:1

in the diagnosis of BPD. It rests on assumptions that (a) to

varying degrees sociocultural factors inevitably play a role

in the expression of disease conditions, and that (b)

personality disorders, including BPD, have cultural

histories. It also rests on the belief, for which there is

considerable scholarly support, that the phenomenon called

BPD has multiple, complex, interactive, biological,

psychological, and constructed sociocultural determinants.

Address correspondence to Pamela Bjorklund, The College of St. Scholastica, 1200 Kenwood

Avenue, Duluth, MN 55811-4199. E-mail: pbjorklu@css.edu

Issues in Mental Health Nursing , 27:3–23, 2006

P. Bjorklund

Nurses must understand the phenomenon at this level of

complexity to provide appropriate care.

FROM THE INSIDE OUT

‘It’ has a name, but the condition is characterized by suffering of

such quality and magnitude that it cannot be clearly articulated. Its ori-

gins are largely preverbal (Adler & Buie, 1979; Gunderson, 1984, 2001;

Kernberg, 1975, 1996; Masterson, 1976, 1988, 2000). It is the sort of

suffering from which suicide seems the only escape. Indeed, the im-

pulse to suicide or self-harm is one of its deﬁning characteristics. It is an

unparalleled poverty of soul and self that leaves its possessor bereft of

identity, alone, and empty in the midst of crowds and plenty, self-hating

to the point of viewing self-extermination as deserved. The annihilatory

threat of abandonment fuels frantic attempts to connect—usually with

those guaranteed to leave. Relationships are doomed. There is no sat-

isfactory distance from others. Distance is too close or too far. There

is no satisfactory level of environmental or interpersonal stimulation.

Stimulation is too much or too little. Here, there can be no Goldilocks .

Nothing is “just right,” and nothing soothes for long—not food, drink,

company, sex, or spending. Desperate attempts to relieve the distress

drive others to distraction. However, when others hate them as much as

they hate themselves, at least they are no longer alone. Someone ﬁnally

feels what they feel.

Paradoxically, its pain is deep and dark, both transient and unrelent-

ing, but purposeful and meaningful. Such pain can provide form and

substance to an easily fragmented, insubstantial, and ultimately illusory

core self, thus constituting an identity of sorts—but not really and not

for long. Self-destructive behavior patterns—evidence of this fragmen-

tary, false self—offer protection from feeling “bad” at the expense of a

meaningful and fulﬁlling life (Masterson, 1988). Sooner or later, life is

so chaotic it seems there is no life left worth living. Most live on anyway

as struggling survivors—their very existence a tribute to the tenacity

of the human spirit, although everyday life feels far from triumphal. A

fortunate few actually get helpful treatment and forge that elusive “life

worth living.” Some die.

FROM THE OUTSIDE IN

‘It’ is called borderline personality disorder (BPD). It is one of ten

personality disorders included in the Diagnostic and Statistical Manual

Bias in Diagnosing Borderline Personality Disorder

of Mental Disorders ( DSM-IV-TR ; American Psychiatric Association

[APA], 2000), which is a taxonomy of psychiatric disorders supported

by an extensive empirical foundation and pervasively used as a guide to

the clinical practice of psychiatry in the United States. Its curious name

reﬂects the initial confusion of both clients and caregivers who struggled

to understand life stories that were perplexing, paradoxical, inconsistent,

contradictory, and dominated to some degree by psychological difﬁcul-

ties that confront us all (Masterson, 1988). In fact, the themes evident

within these struggles reﬂected social trends and psychological themes

in the culture of the United States at large, including a growing sense of

social isolation; the dissolution of social structures that lent coherence

to self-identity (along with the emergence of social customs that ag-

gravated instead of remediated problematic parent-child relationships)

(Millon, 2000); emphasis on the self to the exclusion of others; fear

of abandonment; difﬁculties with intimacy and relationships, and with

creativity and self-assertion (Masterson): “To cover [the] confusion, we

diagnosed these patients as ‘borderline’ because they were sicker than

the neurotic but not sick enough to be classiﬁed psychotic. They were

on the border, somewhere in between. Although this waste basket term

seemed appropriately descriptive, it really said more about our ignorance

on the subject than about what was wrong with the patient” (p. viii).

According to DSM-IV-TR , the essential feature of BPD is a pervasive

pattern of impulsivity and instability of interpersonal relationships, self-

image, and affect that begins by early adulthood and is present in a variety

of contexts. Five of nine criteria must be met for diagnosis, including

“frantic” efforts to avoid abandonment; a pattern of unstable and intense

interpersonal relationships characterized by alternating idealization and

devaluation; identity disturbance (i.e., markedly and persistently unsta-

ble sense of self); impulsivity in at least two potentially self-damaging

areas (e.g., sex, spending, binge-eating, or substance abuse); recur-

rent suicidal and/or self-mutilating behavior; affective instability due

to marked reactivity of mood; chronic feelings of emptiness; inappro-

priate, intense anger; and transient, stress-related paranoid ideation or

dissociative symptoms (APA, 2000, p. 710). It is associated with sig-

niﬁcant psychiatric mortality and morbidity. Approximately 10% of in-

dividuals diagnosed with BPD will eventually commit suicide (Paris,

1993; APA). Not long ago, people with BPD were considered untreat-

able. Today, the research on psychotherapeutic efﬁcacy (APA, 2003;

Fonaghy & Roth, 1996; Koerner & Dimeff, 2000; Nathan & Gorman,

1998) points to two approaches—psychoanalytic/psychodynamic ther-

apy and dialectical behavior therapy (DBT)—as most helpful in treating

BPD. The literature on both is extensive and growing and is not being

P. Bjorklund

reviewed here. Sufﬁce it to say there is now ample documentation to

support real hope that persons with borderline personality disorder can

have lives worth living, learn to share those lives with others in ways

that are healthy, straightforward expressions of their deepest needs and

desires, and in so doing ﬁnd fulﬁllment and meaning (Masterson, 1988).

BACKGROUND

Curiously, approximately 70–77% of those diagnosed with BPD are

female (APA, 2000; Swartz, Blazer, George, & Winﬁeld, 1990; Widiger

&Weissman, 1991), which begs the question of how culture affects both

the prevalence and manifestation of the condition. Clearly, judgments

about personality functioning must take into account an individual’s

ethnic, cultural, and social background, as well as the gender ideologies

that shape behavior (APA; Sargent, 2003). Medical anthropologists have

addressed such topics as the culture of biomedicine, the cultural shap-

ing of psychiatric classiﬁcation, the multiple meanings of body changes

in health and illness, power differentials in doctor-patient relationships,

and cultural variation in conceptions of normality and abnormality (Sar-

gent). Yet few reliable cross-cultural studies of severe personality dis-

order exist (Akhtar, 1995), and there is scant anthropological literature

that directly focuses on either BPD or the self-injurious behavior that

characterizes it (Sargent). Similarly, sociologists have examined sex bias

in psychiatry generally (Busﬁeld, 1989); gender differences in rates of

mental illness as evidence for the social organization of knowledge in

patriarchal societies (Smith, 1990); the ethno- (e.g., cultural) psychol-

ogy that underlies psychiatric classiﬁcation (Gaines, 1992); the nature of

diagnosis and illness as socially constructed (Brown, 1995); the growth

of psychiatric diagnosis as a function of the remedicalization of the

discipline of psychiatry (Rogler, 1997); and problems with the reliabil-

ity and validity of diagnoses of personality disorder generally (Pilgrim,

2001). But rarely have sociologists focused speciﬁcally on BPD, with

the exception of Wirth-Cauchon (2001), who has presented a social con-

structivist account of the borderline diagnosis as the medicalization of

the self-destructive feelings and behaviors of women “that lie at the ex-

treme end of a range of responses to gender contradictions and violence

in late modern society” (p. 211).

PURPOSE

The literature on BPD, including its epidemiology, biology, phe-

nomenology, causes, correlates, consequences, costs, treatments, and

Bias in Diagnosing Borderline Personality Disorder

outcomes is vast. Thousands of articles and books have been published.

Because the true prevalence of BPD by sex in the general popula-

tion is still unknown, the important question of why women, rather

than men, are more frequently diagnosed with BPD largely remains

unanswered—despite current evidence for the origin of personality dis-

order in genetics and neurobiology (Cloninger, 2004; Siever, 2003;

Skodol, Siever, Livesley, Gunderson, Pfohl, & Widiger, 2002; Teicher,

Andersen, Polcari, Anderson, Navalta, & Kim, 2003), and despite recent

suggestions that biased sampling is the most likely explanation for gen-

der (sex) bias in the diagnosis of BPD (Skodol & Bender, 2003). This

paper reviews selected literature on the epidemiology of BPD, gender

bias in the diagnosis of BPD, and the social construction of diagnosis,

particularly the diagnostic entity labeled “Borderline Personality Dis-

order.” It attempts a synthesis of diverse, multidisciplinary literature to

address the question of why women outnumber men by a ratio of 3:1 in

the diagnosis of BPD. It rests on assumptions that to varying degrees,

sociocultural factors inevitably play a role in the expression of disease

conditions and that personality disorders, including BPD, have cultural

histories. It also rests on the belief, for which there is considerable schol-

arly support, that the phenomenon called “Borderline Personality Disor-

der” has multiple, complex, interactive, biological, psychological, and

constructed sociocultural determinants.

LITERATURE REVIEW

Epidemiology of BPD

Etiology

The etiology of BPD has been the focus of clinical interest for

approximately 30 years. The literature related to its determinants is vo-

luminous and was systematically reviewed by Zanarini and Frankenburg

(1997) and Zanarini (2000), who discussed six main conceptualizations

of the term “Borderline;” outlined the seminal theories of its pathogene-

sis; reviewed previously studied etiological factors; organized the litera-

ture into ﬁrst-, second-, and third-generation etiological studies; and pro-

posed a multifactorial model of the complex etiology of BPD consistent

with their conclusion that individuals follow “a unique pathway to the de-

velopment of BPD that is a painful variation on an unfortunate but famil-

iar theme” (Zanarini & Frankenburg, p. 93). They describe (a) Kernberg’s

(1975) conception of the term “borderline” as a level of personality dis-

organization descriptive of the most serious form of character pathology;

Plik z chomika:

Inne pliki z tego folderu:

Inne foldery tego chomika: