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Summer 2018 Issue

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Are There Gender Differences in Borderline Personality Disorder?

Justin Cimring, MD, Candidate 2019
Alexander Pattison, MD
Stephanie Peglow, DO, MPH

In the United States the overall prevalence of personality disorders in the general population is consistently around 10%. Obsessive-compulsive PD is most common, followed by narcissistic and borderline PD (BPD).1 The lifetime prevalence of BPD may be as high as 5.9%.1The DSM-5 suggests that there is a 3:1 female to male gender ratio of BPD clinically,2 however several papers suggest no difference in this rate in the population as a whole.3,4,5

The conflicting data in gender differences raises concern for stigma in diagnosis.  Studies from 30 years ago suggest clinicians maintained slight gender bias in diagnosing BPD in favor of females.6 A study in 2003 examining gender bias in diagnosing BPD indicated that no such bias exists.7 This suggests that if more women are diagnosed with BPD but population prevalence between genders is equal, women may be more likely to seek treatment than men. Another possible explanation is that women with BPD may exhibit traits that more negatively affect function, thus leading to increased rates of hospitalization and diagnosis. If there is truly a gender difference among patients with BPD, it may be due to cultural underpinnings or behavior differences among genders.8 

Behavior differences may be manifested as differential symptom clusters by gender or by differences in co-morbidities. A previous study explored if women and men with BPD manifest symptoms differently. In general, most symptoms are expressed with similar prevalence among men and women (see Table 1). Men, however, tend to express explosive temperaments and novelty seeking, whereas women express more depressive, anxious, and somatic symtoms.9,10 Other investigations into BPD gender differences suggest comorbidity and treatment utilization may affect our perception of gender heterogeneity.8 Men with BPD are more likely to have a comorbid substance use disorder;8 associated personality traits may complicate diagnosis of a distinct personality disorder.  Women, on the other hand, are more likely to have comorbid eating, mood, anxiety and post-traumatic stress disorders.8 Finally, men are more likely to be involved in substance treatment programs while women with BPD tend to be high utilizers of pharmacotherapy and psychotherapy.8  Hence it is possible that gender bias in diagnosing BPD are less related to differential prevalence but differential presentation.

Table 1: The diagnosis of borderline personality disorder with associated prevalence of symptoms present in those with confirmed diagnosis BPD in parenthesis.2,11

  1. Affective instability (95%) – Due to marked reactivity of mood (intense episodic dysphoria, irritability, or anxiety usually lasting a few hours)
  2. Inappropriate anger (87%) – Inappropriate, intense anger or difficulty controlling anger (frequent temper tantrums, constant anger, recurrent fights)
  3. Impulsivity (81%) – In at least two areas that are potentially self-damaging (spending, sex, substance abuse, reckless driving, binge eating)
  4. Unstable relationships (79%) – Pattern of unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation
  5. Chronic feelings of emptiness (71%)
  6. Paranoia or dissociation (68%) – Transient, stress-related paranoid ideation or severe dissociative symptoms
  7. Identity disturbance (61%) – Markedly and persistently unstable self-image
  8. Abandonment fears (60%) – Frantic efforts to avoid real or imagined abandonment
  9. Suicidality or self-injury (60%) – Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

References:

  1. Sansone RA, Sansone LA. Personality disorders: a nation-based perspective on prevalence. Innovations in Clinical Neuroscience. 2011;8(4):13-18.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
  3. 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. The Journal of Clinical Psychiatry. 2008;69(4):533-545.
  4. Coid J, Yang M, Tyrer P, Roberts A, Ullrich S. Prevalence and correlates of personality disorder in Great Britain. British Journal of Psychiatry. 2006; 88:423-431.
  5. Jackson HJ, Burgess PM. Personality disorders in a community: a report from the Australian National Survey of Mental Health and Well-Being. Social Psychiatry and Psychiatric Epidemiology. 200;35:531-588.
  6. Henry KA, Cohen CI. The role of labeling processes in diagnosing borderline personality disorder. American Journal Psychiatry. 1983;140(11):1527-9.
  7. Strain BA. Influence of gender bias on the diagnosis of borderline personality disorder. Dissertation Abstracts International. 2003; 64:2941B.
  8. Sansone RA, Sansone LA. Gender Patterns in Borderline Personality Disorder. Innovations in Clinical Neuroscience. 2011;8(5):16-20.
  9. Barnow S, Herpertz SC, Spitzer C, et al. Temperament and character in patients with borderline personality disorder taking gender and comorbidity into account. Psychopathology. 2007;40:369–378.
  10. Silberschmidt A, Lee S, Zanarini M, Schulz SC. Gender differences in borderline personality disorder: results from a multinational, clinical trial sample. Journal of Personality Disorders. 2015;29(6):828-38.

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