Is Borderline Personality Disorder a Gender-Biased Diagnosis?

Senin, 11 Januari 2010

According to DSM-IV-TR, BPD is “diagnosed predominantly (about 75%) in females” (American Psychiatric Association 2000, p. 708). A female- to-male gender ratio of 3:1 is quite striking for a mental disorder and suggests the possibility of sampling or diagnostic bias or of biological or sociocultural differences between women and men that lead to the development of BPD.

A sampling bias can occur if the proportion of women with BPD is no greater than the proportion of women versus men seen in a clinical setting. If women were three times more likely to seek help for psychological problems, then it would be no surprise that the disorders found would appear on average to be three times more common in women.

Most studies in clinics that have used standardized interview assessments have found no greater proportion of women with BPD than of all women treated in the setting, suggesting that a sampling bias may account for at least some of the higher observed prevalence of BPD in women. There are as yet too few studies of BPD in the general population to know what the real gender ratio may be.

Diagnostic biases may exist if the construct of BPD or its criteria reflect a sexist characterization of female behavior as pathological, or if women exhibiting the same traits or behaviors as men would be more likely to be labeled as abnormal. Another diagnostic bias would exist if errors in making the diagnosis of BPD were more common for female patients than for male patients. A number of studies have shown that BPD criteria, except anger, may be considered slightly more characteristic of women than of men (Sprock et al. 1990) and more pathological in women (Sprock 1996). A study by Johnson et al. (2003) showed that women and men with BPD are more similar than different. Women may demonstrate their impulsivity differently than men do—for example, by engaging in binge eating rather than substance abuse. Also, female patients receive unwarranted diagnoses of BPD more often than do male patients, but, surprisingly perhaps to the gender-bias theorists, misdiagnosis occurs more often when the clinician is also a woman. Although there is modest support for diagnostic biases of various kinds, none of these are strong enough to account for the wide difference in prevalence reported. If the true prevalence rate of BPD in women is higher than that in men, it would have to be the result of biological or sociocultural factors.

Among the possible risk factors for BPD (Table 1–2), some have been found to be more common in women. For example, the personality trait of neuroticism (emotionality, impulsivity, vulnerability to stress), which is thought to underlie BPD and is under genetic influence, occurs more frequently in women. Childhood sexual abuse, which has been implicated in the genesis of BPD, is 10 times more common in women than
in men. Different rearing practices lead boys to develop more externalizing, action-oriented ways of dealing with problems and stress, whereas girls are often reared to be more internalizing and emotional. Future studies are needed to shed light on gender differences in biological and social processes that may foster the development of BPD.