Where are all the men?: Controversy in BPD – Part 6

Discrepancy in Gender Diagnosis
Why does it seem that men have such a low frequency of Borderline Personality Disorder?  There seems to be two main reasons.
1.)    Men are diagnosed with something else.
2.)    Men are more likely to be treated only for their major presenting symptoms.
Some studies have reported that men are more likely to be diagnosed as paranoid, passive-aggressive, narcissistic, sadistic, or with anti-social personality disorder. I’ve done a lot of research into BPD (clearly) and I’ve often come across articles that focus on BPD with ASPD. Primarily the subject study group for BPD is women, and the study group for ASPD is men. This is not necessarily an accurate distinction though.
Men and women do often present with different symptoms when you break it down to Axis I and Axis II comorbid criteria. However these symptoms are still all encompassed in the range of BPD diagnostic criteria.
Axis I co-morbid disorders:
Men with BPD tend to have higher rates of substance use disorders, while women have higher rates of PTSD and eating disorders.
There isn’t a significant difference in frequency though. These things are pretty much expected with you take into account general psychopathology/temperamental differences in gender. In things like major depressive disorder, anxiety disorders, or mood disorders there was not found to be any significant difference in BPD diagnosed gender representation.
Axis II co-morbid disorders:
There is significant difference in how men and women present in Axis II disorders which are the presentation of other personality disorder traits. Men are found to have higher rates of antisocial, narcissistic, and schizotypal personality disorders.
When you take a look at the diagnostic criteria for BPD the only real significant difference is women tend to have greater frequency of identity disturbance. Men do present slightly higher in Intense Anger and Impulsivity criteria while women tended to be a little higher in Affective instability and Avoiding abandonment.
When it comes to diagnosis between genders in BPD it was found that the function of impulsivity, how men and women tend to differ in the specific type of impulsive behavior displayed, were often different, even though the frequency was negligible. That is, Acting In or Acting Out. While women might tend towards food (internalizing behavior) men might turn towards drugs or alcohol (externalizing behavior) for self-destructive behavior. But because men tend towards externalizing it is easier to overlook the other more passive/internalized symptoms.
More aggressive acting out is likely to overshadow other symptoms that are also present. So men will be referred to anger management or therapy will focus on that particular displaying symptom, what brings it out, how to react appropriately. Or try to. I don’t know how well this works if you’re only treating one symptom and not the entire problem. Or take something like alcohol/substance abuse for example. If a woman walks into therapy and says she has a drinking problem the therapist is likely to delve into the more emotional reasons for drinking. Social stigmas for men tend to focus on the physical problem, focus on rehab and detox. They might ask what events make them want to drink and suggest how to cope with these, but not as likely to look into why they are more prone to having these reactions that cause them to imbibe in the first place.  
Additionally, finding men to have higher co-occurrences of Personality Disorders is consistent with basic differences in how men and women relate to others socially. Women are socialized to be more interpersonally connected then men. A higher percentage of men with BPD also having antisocial, narcissistic, and schizotypal PDs shows increased difficulty in relatedness to others, a typical gender difference in the more pathological forms of these PDs. For example, in a sample comprised of inpatients and outpatients, men scored significantly higher on mistrust, manipulativeness, aggression, entitlement, detachment, and disinhibition, while women scored significantly higher on negative temperament, dependency, and propriety. Because the presentation of these symptoms is different, and there is a stigma towards the more passive symptom presentations, it is easier to overlook BPD as a diagnosis in favor of a more aggressive diagnosis, like ASPD for men.
All of this muddies the ability to make distinct diagnosis in men, because there may not be a distinct diagnosis for some men or they’re not being treated for their whole problem.
Maybe men should just seek psychiatric treatment more often so clinicians can get a better idea of how their PDed brains work and take some of the stigma off of us. Come on guys, help us out here. Just kidding.  Sort of. ::smiles::

Co-Morbid Symptoms: Borderline Personality Facts and Statistics Part 5

– On the Minnesota Multiphasic Personality Inventory (MMPI), ERD patients do not show a common profile. Personality traits appear to be a combination of histrionic, narcissistic, and antisocial personality.
The MMPI is one of the most frequently used personality tests in mental health. The test is used by trained professionals to assist in identifying personality structure and psychopathology. I don’t actually know much about this test so I’ll be sure to do more research on this in the future.  However it doesn’t surprise me that BPD displays with a combination of personality disorder traits.  Since personality disorders encompass all aspects of a person’s life, the environmental and emotional factors that are experienced often overlap.  The very nature of BPD is a collection of problems that display together…

– Co-morbid conditions in BPD may also affect the ability to act responsibly.
BPD is not a single issue.  There is no single thing that you can point to and say, yep, that’s BPD. BPD is often referred to as a ‘catch-all’ personality disorder because there are so many influencing factors.  Rather than the type of symptom, are the number of proliferative psychiatric or medical symptoms that are diagnostically relevant. These multiple psychiatric symptoms appear to manifest as numerous comorbid Axis I and II diagnoses.  
Axis I:  Clinical disorders, including major mental disorders, and learning disorders
<!–[if !supportLists]–>          <!–[endif]–>Axis II: Personality disorders and mental retardation (although developmental disorders, such as Autism, were coded on Axis II in the previous edition, these disorders are now included on Axis I)

Axis I disorders – Clinical ( Mental ) Disorders are used to report various disorders or conditions, as well as noting other conditions that may be a focus of clinical attention. Clinical Disorders are identified into 14 categories, including:  Anxiety Disorders, Childhood Disorders, Cognitive Disorders, Dissociative Disorders, Eating Disorders, Factitious Disorders, Impulse Control Disorders, Mood Disorders, Psychotic Disorders, Sexual and Gender Identity Disorders, Sleep Disorders, Somatoform Disorders, and Substance-Related Disorders. Other conditions, known as Adjustment Disorders, may also be a focus of clinical attention includeMedication-Induced Movement Disorders, Relational Problems, Problems Related to Abuse or Neglect, Noncompliance with Treatment, Malingering, Adult Antisocial Behavior, Child or Adolescent Antisocial Behavior, Age-Related Cognitive Decline, Bereavement, Academic Problem, Occupational Problem, Identity Problem, Religious or Spiritual Problem, Acculturation Problem, and Phase of Life Problem.

Axis II disorders – Personality Disorders and Mental Retardation are recorded so the clinician will give consideration to additional intervention and treatment choices. Personality is the qualities and traits of being a specific and unique individual. It is the enduring pattern of our thoughts, feelings, and behaviors, it is how we think, love, feel, make decisions and take actions. Personality is determined, in part, by our genetics and also, by our environment. It is the determining factor in how we live our lives. Individuals with Personality Disorders have more difficulty in every aspect of their lives. Their individual personality traits reflect ingrained, inflexible, and maladaptive patterns of behaviors that cause discomfort, distress and impair the individual’s ability to function in the daily activities of living. In Mental Retardation problems in brain development have usually occurred and virtually will affect all aspects of the individual’s cognitive functioning. Borderline Intellectual Functioning, as well as Learning Disabilities, may also be a consideration for clinical focus.
Common Axis II disorders:

Antisocial Personality Disorder.
Avoidant Personality Disorder.
Borderline Personality Disorder.
Dependent Personality Disorder.
Histrionic Personality Disorder.
Mental Retardation.
Narcissistic Personality Disorder.
Obsessive-Compulsive Personality Disorder.
Paranoid Personality Disorder.
Personality Disorder Not Otherwise Specified.
Schizoid Personality Disorder.
Schizotypal Personality Disorder.
I’ve mentioned co-morbid symptoms before as I have a metric butt-ton of these: Clinical Depression, General Anxiety Disorder, Eating Disorder (Bulimia), Dissociative Disorder, Sleep disturbance, Sexual/Gender Identification ‘issues’ (I don’t find this to be an issue at all), and possibly substance abuse problems (alcohol). Not to mention the obvious DSM criteria that qualify me for the Axis II Borderline Personality diagnosis.
When there are so many issues, so many overwhelming features to BPD it’s not at all surprising that it’s difficult for someone with BPD to act responsibly. It’s a lot to keep in mind, a lot to try to reign in. These are not issues that can be flipped on and off like a light switch, easily kept in check. You don’t get to choose when your emotions affect you, or how they affect you. And this CAN happen at the flip of a trigger in almost any situation. All of these things contribute to what makes BPD so difficult to control, and that lack of control comes out when we don’t want it to.