Hysteria, Borderline Personality Disorder, and Sexism

What is Borderline Personality Disorder?

According to the National Institute of Mental Health (NIMH), borderline personality disorder (BPD) "is a serious mental disorder marked by a pattern of instability in moods, behavior, self-image, and functioning."

People with borderline personality disorder may experience:

  • intense episodes of anger,

  • depression,

  • and anxiety that may last from only a few hours to days.

"These experiences often result in impulsive actions and unstable relationships."

Borderline personality disorder (BPD) is highly stigmatized and remains far behind other major psychiatric disorders in awareness and research, says John G. Gunderson, MD.

Is BPD a Sexist Diagnosis?

Feminist mental health expert Jessica Taylor (FRSA, PhD) thinks so.

In the above Twitter image, @DrJessTaylor writes:

"Borderline personality disorder in DSM-V has the same diagnostic criteria as hysteria did in DSM-II.
Let that shit sink right in."

Taylor's work with Victim Focus includes critiquing the psych field that is quick to label pathologies on women - especially women and populations who are disproportionally impacted by physical and sexual violence.

Are we vilifying victims?

Harvard Health School reports three times as many women as men are being diagnosed with borderline personality disorder.

Talkspace (a virtual therapy coordinating site) asks, "Is it sexism that perpetuates this gender disparity?"

And answers: "Possibly. While women are more likely to get a diagnosis of mental illness overall, doctors are still less likely to take their symptoms — physical or mental — as seriously."

Diagnostic Criteria

The pinnacle of health is the adherence to the highest standards as set by your by society (macro influence) and social network (micro influence). It's the optimal level at which you are a productive, functioning, and law-abiding citizen who conforms to the social norms as imposed and expected. The better you are at assimilating, the less hassle you'll receive by way of external judgement or shame.

Any deviance in 'normal' thinking or behaviour is a red flag in this psych model.

So what makes an abnormal personality? It depends on a number of socio-economic and cultural factors.

Biskin and Paris say the current diagnostic criteria for borderline personality disorder allows for 256 different combinations of symptoms that could lead to a diagnosis. This is 256 combinations of "symptoms" that are other to a normal we cannot measure outside its relation to current culture.

"Women are more likely than men to have BPD."

The DSM defines BPD as a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:

  1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviour covered in criterion 5.

  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. (AKA splitting or split-thinking)

  3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

  4. Impulsivity in at least 2 areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour covered in criterion 5.

  5. Recurrent suicidal behaviour, gestures or threats, or self-mutilating behaviour.

  6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).

  7. Chronic feelings of emptiness.

  8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Talkspace says the manifestation of BPD symptoms can arise, change, or disappear as fast as they are diagnosed.

The U.S. Department of Health & Human Services Office on Women's Health states on their educational site for borderline personality disorder that, "Women are more likely than men to have BPD."

There is no explanation for the gendered difference or confirmation of cause.

Surface Level History Lesson

The history of hysteria and personality disorders shows the power of language and its evolutionary impact on how we understand mental illness. It also highlights the unique cultural setting in which minds are considered healthy - and why. Hysteria as a diagnosis lasted about 100 years from 1880 until it was removed from the DSM in 1980. During that time, its meaning evolved from a physical ailment of the uterus to a mental illness. McGill's Office for Science and Safety says,

Hysteria was basically the medical explanation for ‘everything that men found mysterious or unmanageable in women’, a conclusion only supported by men’s (historic and continuing) dominance over medicine, and hysteria’s continued use as a synonym for “over-emotional” or “deranged.”

In the late 1930s, Adolph Stern introduced borderline personality disorder to describe a group of patients who ‘fit frankly neither into the psychotic nor into the psychoneurotic group.’ In this example, he saw his patients as "borderline" to schizophrenia. Later, it would be discovered that BPD is not related to schizophrenia. However, experts say BPD is a diagnosis with high comorbidity and its symptoms overlap considerably with depressive, schizophrenic, impulsive, dissociative, and identity disorders. Toward the 70s, the BPD label came to signify a "middle level of personality organization" that could be treated with psychoanalytic psychotherapy. This means doctors thought talk therapy based on Freudian theories would fix it—the "it" being a sub-par integration into society's standards and expectations.

In 1980, BPD entered the DMS-III and became an "official" psychiatric diagnosis. Controversy over its origins flare between different schools of thought.

Gunderson lists research findings from the decade between the 80s and 90s.

  • BPD is an internally consistent, coherent syndrome

  • with a course that differs from those of schizophrenia and major depression

  • the syndrome is familial

  • abuse was found in (at least) 70% of those with BPD

  • feminist clinicians suggest BPD as pathologizing women & blaming victims

Between 2000-2009, BPD's heritability was determined and BPD was reframed as a "brain disease." It was also found that BPD is a "good prognosis-diagnosis."

Gunderson says, "Borderline personality disorder has moved from being a psychoanalytic colloquialism for untreatable neurotics to becoming a valid diagnosis with significant heritability and with specific and effective psychotherapeutic treatments."

Feminist Perspective

Taylor says we're moving into a strict medical model that disallows women to experience any trauma without being told they're disordered. Sylvia Plath's iconic female protagonist Esther Greenwood comes to mind. She is markedly different after escaping Marco's rape attempt. The whole script is arguably different - the path she was on no longer available as though it has been stolen just the same. She leaves school and is eventually institutionalized with treatment-resistant depression.

Taylor says the symptoms of BPD are trauma responses; treating them like something to be "cured" (perhaps rather than healed?) shows how little the DSM takes into account trauma theory.

Trauma theories developed in the 90s out of the psychoanalytic Freudian landscape.

According to the blog Literary Theory & Criticism, "Freud’s theories—that traumatic experiences are repeated compulsively, divide the psyche, influence memory differently than other experiences, and are unable to be experienced initially but only in a narrative reproduction of the past—are key ideas informing the first development in trauma studies scholarship that address the theory of trauma and the ways that trauma influences memory and identity."

"In Freud’s early work he argues that traumatic hysteria develops from a repressed, earlier experience of sexual assault."

In other words, women react to being sexually assaulted in maladaptive ways because #repression and #survival. Pathologizing them by way of a BPD diagnosis is victim blaming.

Experts say trauma has been medicalized by way of adding the PTSD diagnosis into the DSM-III in 1980. The BPD diagnosis was added the same year.

Talkspace says BPD is the most common condition currently associated with classical “hysteria." Classical hysteria was exclusive to women, a historically gendered diagnosis that often served as a catch-all when doctors couldn’t identify another illness.

When the FDA came out with a so-called miracle med for curing BPD, Taylor took to YouTube. In the five minute video, Taylor says she can see right through this - a drug claiming to be able to medicate and change personality.

"Personality itself is a contested concept, all over the world personality is perceived differently," she says.

Taylor says the way we measure personality - the metrics that we use - are not accurate, and they're not culturally specific.

"They're not even specific to the time and the place of the human. They don't see personality as in flux, as being flexible and changeable and different at different stages of our lives."

"They're sexist," she says of the metrics. Taylor reiterates that BPD disproportionally effects young girls and women who are victims of abuse and trauma.

"While the discussion of women and mental illness may have become less blatantly sexist in recent years, it is clear that there is still an unfortunate yet commonly held belief that women are more prone to mental illness and to “abnormal” behavior (“normal behavior” often being a proxy for male behavior)," says Talkspace.

"It's a pathologization of trauma," says Taylor.

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