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BPD PDF
BPD PDF
Address correspondence to Pamela Bjorklund, The College of St. Scholastica, 1200 Kenwood
Avenue, Duluth, MN 55811-4199. E-mail: pbjorklu@css.edu
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BACKGROUND
PURPOSE
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;
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BPD reported more severe forms of sexual abuse; and sexual abuse typ-
ically took place in an environment of bi-parental neglect and abuse
(Zanarini).
Given that most victims of sexual abuse are female, these etiological
findings may partially explain the gendered nature of BPD. What seems
clear, based on the research literature to date, is that a multifactorial
model of the etiology of BPD best captures its complexity: “This model
suggests that BPD symptomatology and its comorbid manifestations are
the end product of a complex admixture of innate temperament, difficult
childhood experiences, and relatively subtle forms of neurologic and
biochemical dysfunction (which may be sequelae of these childhood
experiences or [of] innate vulnerabilities)” (Zanarini, 2000, pp. 98–99).
What this model neglects is any suggestion of the socially constructed
aspects of diagnosis and illness (Brown, 1995).
Prevalence
In addition to etiology, the concept of prevalence (i.e., the rate of
cases during a particular time frame) is important to an epidemiological
understanding of a disorder. The epidemiological data on the prevalence
and incidence (i.e., the rate of new cases in a population) of border-
line personality disorder is very limited. Widiger and Weissman (1991)
reviewed the existing epidemiological literature on BPD and found a
prevalence rate between 0.2 and 1.8% in the general population, along
with a prevalence rate of 15% among psychiatric inpatients and 50%
among those psychiatric inpatients with a diagnosis of personality dis-
order. Their meta-analysis suggested that 76% of patients with BPD are
female. The DSM-IV-TR (APA, 2000) also reports a 3:1 sex ratio for
BPD, but it finds a higher prevalence (20%) of BPD in psychiatric inpa-
tients as well as a higher prevalence (2%) in the general community. In
addition, it reports that in the United States, BPD is seen in about 10% of
all clients treated in outpatient mental health settings—which is higher
than the 8% of all outpatients reported by Widiger and Sanderson (1997).
It is not clear if the actual prevalence of BPD is increasing over time.
The high prevalence of BPD compared to other personality disorders
in clinical samples—27% of outpatients with a diagnosis of personality
disorder (Widiger & Sanderson, 1997)—is striking given that BPD is far
from the most common personality disorder found in community sam-
ples. Samuels, Eaton, Bienveu, Brown, Costa, & Nestadt (2002) who
assessed the frequency of DSM-IV and ICD-10 personality disorders in
a community sample between 1997 and 1999 found, for example, that
BPD has a weighted prevalence of 0.5% compared to a weighted preva-
lence of 0.9% for obsessive-compulsive personality disorder, 1.8% for
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Akhtar (1995) has suggested that cultural factors might underlie the
differences in the seemingly gender-related manifestations and preva-
lence of severe personality disorders. For example, the much lower
prevalence of antisocial personality disorder among women might be
related to the more intense social control of women’s behavior. As so-
cietal attitudes shifted and women were allowed greater freedom and
access to all means of self-expression, the prevalence of antisocial per-
sonality disorder among females increased. Sargent (2003) speculated
that BPD and the bodily self-injury that characterizes it occur in the
context of such gender ideologies, perhaps in class-based, industrialized
societies where the female body is highly commodified. Certainly, there
are gendered expectations concerning both the emotionality and rela-
tional context of BPD. Women are simply thought to be more emotional,
relationally-defined, and relationship-dependent than men. Clearly, gen-
der stereotypes affect women and their experiences (and expression) of
mental illness (Wright & Owen, 2001).
Horsfall (2001) argued that gendered assumptions are embedded in
psychiatric knowledge and that BPD is essentially a gendered construct
arising from a psychiatric classification system that is itself a social
construction. She described the term “gender” as “introduced into com-
mon parlance. . . . to conceptually separate female and male biological
factors (sex) from social and culturally derived behaviors, expressions
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is that the first person complies with the full prototype, while the other
does not” (Johansen et al., p. 290). This study confirmed the prototype
nature of the DSM-IV borderline construct. It concluded that the BPD
diagnostic category has high validity as a prototype and that only minor
revisions to the DSM-IV criterion hierarchy are required. The authors do
not explain, of course, why females outnumber males by a ratio of 3:1
within this (valid) prototype category.
Clearly, even if personality disorders exist with differential sex preva-
lence rates consistent with the normative differences between men and
women, diagnosis would still be biased if different thresholds are used
for male-typed (e.g., antisocial) versus female-typed (e.g., borderline
or histrionic) personality disorders, or if diagnostic criteria in clinical
practice are differentially applied (Widiger, 1998). Widiger reviewed ev-
idence for both types of bias, as well as evidence for bias in the diagnostic
instruments used in BPD research. Sampling bias presents a particularly
potent source of gender bias in BPD. It is possible that the perception of
differential sex prevalence rates in personality disorder is an artifact of
the higher rate of females in clinical settings: “If 75% of the persons at a
clinic are female, then one would expect, by chance alone, that 75% of
the persons with any particular disorder will also be female. Therefore,
it might not be particularly meaningful to find that 75% of the persons
with a. . . [borderline] personality disorder are female” (Widiger, p. 105).
Nevertheless, the simple fact that more females than males are present
at any particular clinic does not imply that there are more females than
males in every disorder, including BPD, diagnosed at that clinic (Widiger
& Weissman, 1991). Ultimately, the differential sex prevalence rate of
BPD can only be determined accurately from studies that use probability
samples of community populations, of which there has been only one to
date (Skodol & Bender, 2003; Torgersen et al., 2001).
Skodol and Bender (2003) reviewed Widiger’s (1998) discussion of
possible sources of sex bias in diagnoses of personality disorder and
completed an updated, comprehensive review of the extant empirical re-
search on the pronounced 3:1 gender (sex) ratio in BPD. Conceding that
the true prevalence of BPD is unknown, they framed the essential ques-
tion as whether the higher rate of BPD in females is due to sampling or
diagnostic bias, or due to biological or sociocultural differences between
the sexes. They cited five empirical studies that used semi-structured di-
agnostic interviews to test for gender differences in DSM III-R and DSM
IV personality disorders, only one of which found that the rate of BPD
differed by gender. They also cited one study that showed BPD was one
of several personality disorders that occurred more often among men.
They speculated that the elevated base rate of women in clinical settings
14 P. Bjorklund
may be the reason why clinicians perceive more women to have BPD.
Ultimately, they concluded that the modest empirical support for diag-
nostic biases of various kinds would not account for the wide difference
in prevalence between males and females and that the differential gen-
der prevalence of BPD in clinical settings is largely a function of biased
sampling. They left a wide opening for the possibility that biological
and/or sociocultural factors may account for the gender difference if, in
fact, the “true prevalence” of BPD in the community is eventually found
to differ by gender (Skodol & Bender).
with it, are suspect; for the statistics themselves are socially constructed
(Brown, 1995). Smith (1990), for example, discoursed on the social
organization of objectified forms of knowledge as integral to the power
relations of contemporary societies. She investigated the statistics on
gender differences in rates of mental illness in Canada and the United
States as an example of this form of socially organized, objectified
knowledge concealing power relationships in patriarchal societies. She
critically analyzed the procedures used to create statistics that pointed to
gender differences in rates of mental illness, and she explored the social
relations and embedded power differentials that produce such statistics.
Moving through and behind possible explanations why the Canadian
figures do not show the same kind of relationship between gender (sex)
and mental illness as do those in the United States, Smith argued that
the process of becoming mentally ill is one in which psychiatric organi-
zations participate: “Put simply, in terms of the statistical information,
this means that when you seem to be counting people becoming men-
tally ill you are in fact also counting what psychiatric agencies do. The
two aspects can’t be taken apart. The figures can’t be decontaminated”
(p. 117). With respect to BPD and the statistics on its prevalence, one
cannot therefore separate the numbers from the actions of an institution
(i.e., psychiatry) that “acts to control people who have come to be seen
as breaching, disrupting, or disorganizing the everyday/everynight and
taken-for-granted accomplishments of a recognizable world” (Smith,
p. 133).
aims. . . [in stripping women] of their power to ask for help” (Luhrmann,
2002, p. 259).
CONCLUSION
REFERENCES
Adler, G., & Buie, D. (1979). Aloneness and borderline psychopathology: The possible
relevance of child developmental issues. International Journal of Pschoanalysis, 60,
83–96.
Akhtar, S. (1995). Quest for answers: A primer of understanding and treating severe
personality disorders. Northvale, NJ: Jason Aronson.
Bias in Diagnosing Borderline Personality Disorder 21