There are some mental illnesses that we hear about more than others. One of the ones we never usually hear about is Borderline Personality Disorder. Making up 1-2% of the general population but about 20% of in-patient admissions, Borderline Personality Disorder is a serious mental illness. Interestingly, it is also an illness where the gender bias is strong – 75% of diagnoses are handed to women. Whilst many mental health problems are more often diagnosed in women, the ratio of diagnoses of BPD is more obvious than most.
It is thought that around 70% of those diagnosed with BPD have been victims of sexual violence. Given the bias towards females as victims of sexual violence, it is thus perhaps not surprising that an illness so closely tied to surviving that kind of assault, is more often handed out to women than to men. This, however, does not begin to fully realise the gendered nature of this diagnosis. For starters, it raises a difficult question about the pathologising of reactions to surviving such horrific crimes. In particular, many people question the name of the disorder. If it is, so often, a reaction to a traumatic life event, or events, why is it characterised as a disorder of one’s personality – as opposed to a post-traumatic reaction?
In fact here we may stumble upon the crux of the problem. Experts in the field argue that men who meet similar criteria would be diagnosed instead with Post Traumatic Stress Disorder. Arguably, due to its association with soldiers, it is one of the most understood and least stigmatised mental illnesses. There is a surprising correlation between symptoms: difficulties with attachment, outburst of anger, intense anxiety, disassociation – all of these things are listed as symptoms of both Borderline Personality Disorder and Post Traumatic Stress Disorder. Yet the former is one of the least discussed – and most stigmatised – mental health problems, whilst the latter is one of the best researched and understood. The former is the label handed to working-class single mums who have been on the receiving end of years of abuse, whilst the latter is handed to officers and cadets that have fought for their country. This is not a coincidence.
Some would argue that the key difference between the two diagnoses is that Post Traumatic Stress Disorder is a temporary condition, whilst Borderline Personality Disorder is a life-long one. Firstly, that is simply not true, as many studies testify to the complete recovery from Borderline Personality Disorder – some argue, in fact, that time is still the greatest healer. The Diagnostic and Statistical Manual itself is coming to the realisation that the distinction between axis 1 (‘illnesses’) and axis 2 (‘disorders’) is an unhelpful and arbitrary one. The idea that mental illness, like physical illness, sits in two distinct categories – those that one recovers from, and those that one deals with – is as archaic as bedlam itself.
Secondly, I would hypothesise that the pathologising of ‘anger’ and ‘impulsivity’ that is so key to the BPD diagnosis would simply not be seen as a problem in men. In other words, a man may recover from PTSD but still express ‘irrational’ levels of anger and impulsivity, and this is seen as normal. On the other hand, when a woman is recovering from the intense emotional reaction following her trauma, she is still considered ill because she might at times shout and hit people in a way that is simply not ‘ladylike’. The criteria for personality disorders includes the following telling line: “the impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.” The impulsive sex or occasional punch-ups of a man that has recently experienced trauma are, I would argue, likely to be considered normative for his socio-cultural environment.
We’ve all heard of hysteria, and the weird psychiatric beginnings of the vibrator. Yet we often openly and brazenly accept the psychiatric definitions of today. In reality, psychiatry as a field is designed to separate the normal from the ‘abnormal’. Its very existence is equivalent to the admission of the norm-seeking nature of society. It is thus perhaps unsurprising that, within it, one can find many areas where it would seem to be tied up with the norms of gender roles of today. A field whose diagnostic criteria rely so heavily on one human being’s judgement of another, is wide open to the infiltration of norms and expected behaviours of society.
The gendered nature of mental illness does not, however, end with diagnosis: it also creates an environment of discrimination and distrust within the mental health services. The movers and shakers of both historical and modern day psychiatry are white men. It is not surprising therefore that such a field struggles to deal with the overarching power dynamics and stereotypes of the society we live in. It was once said to me that if a transgender person, a rabbi and a black woman were responsible for founding early psychiatry we would have completely different notions of mentally healthy and mentally ill.
There is therefore a gaping need for those acting and advocating for feminism, to think and talk about the intersectionality with issues of mental illness. In a world that is talking more and more about mental illness, we must be careful not to lose our rationality and ability to question, even when those that are making the statements are psychiatrists. We are at a point where we are shaping, in our daily lives, the way mental illness will be seen by the next generation. To do this fairly, we must submit psychiatric diagnosis to the same level of scepticism and questioning as we do other facets of a gendered, and white-men-led system.