PTSD and Borderline Personality Disorder: A Gendered Divide in Diagnosis?

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Article written by Christina Vanvuren

As with many types of traumatic or mental disorders, certain criteria must be met to receive a diagnosis. Following the structure of these guidelines is meant to allow for an accurate and unbiased determination. However, when it comes to the differentiation between Post-Traumatic Stress Disorder (PTSD) and Borderline Personality Disorder (BPD), the question of whether men and women are diagnosed differently has been raised.

According to NAMI, the National Alliance on Mental Illness, an estimated 1.6% to 5.9% of adults in the U.S. have BPD. And of those actually diagnosed, 75% were women, despite the fact that men are just as likely to display symptoms. A non-profit organization, PTSD United, found that roughly 8% of Americans have PTSD. Additionally, 1 out of 9 females in the U.S. have PTSD, while the rate for males is about half that. These statistics alone call for us to question whether there is a divide in diagnosis based on gender. Before we can safely address the issue of gender, though, it’s important to look at the symptoms and characteristics that are used to diagnose both Borderline Personality Disorder and Post-Traumatic Stress Disorder.

For a mental health professional to diagnose a patient with BPD, they must display at least 5 of the qualifying symptoms. These include unstable relationships altering between idealization and devaluation, frantic efforts to avoid social abandonment, a distorted self-image that affects emotional stability, impulsive behaviors, suicidal and self-harming behavior, periods of depression, irritability, or anxiety that last between a few hours to a few days, chronic boredom or feelings of emptiness, uncontrollable anger, and dissociative feelings. Most psychological research indicates the causes are genetic, environmental (from the experience of a traumatic event), neurological, or a combination of the three.

When it comes to PTSD, an even hardier list of qualifications must be met to receive a diagnosis. There are qualifying traumatic events like death, serious injury, or sexual violence that a patient must either have experienced themselves or been a witness to. Then, there are four sets of symptom types, that include a variety of symptoms: re-experiencing the event through memories, flashbacks, or nightmares; avoidance of thoughts, feelings, people, or situations connected to the traumatic event; negative alterations in mood or cognitive functions, including negative thoughts, distorted sense of blame, and feelings of detachment or isolation; and, lastly, increased arousal symptoms like difficulty concentrating, irritability, and hypervigilance. In addition, these qualifying symptoms must have lasted for at least a month. Causes of PTSD are correlated to the experience of a traumatic event, not pre-existing genetic susceptibility or neurological disorders.

This opens up the discussion of whether men and women are diagnosed with either BPD or PTSD differently, according to gender. While, statistically speaking, women are about twice as likely as men to meet the criteria for PTSD, the symptoms of BPD are often looked at as stereotypically feminine behavior. For example, while men are viewed as non-emotional and prone to anger, these traits in women may seem abnormal (based on the societal construct of how each gender is supposed to act) — and women are diagnosed accordingly. Speaking to this disparity, some studies have found that doctors are more likely to diagnose women with BPD, even if a male patient is exhibiting the exact same symptoms. The male patient would, instead, be more likely to be diagnosed with PTSD, or treated for alcohol or substance abuse.

The theory of sexual abuse and its impact on whether a diagnosis of BPD or PTSD is given also plays a large role in addressing the gender divide. Women are more likely to both experience and report rape or sexual assault than men are. It’s perhaps this lack of reporting and willingness to seek psychological help that skews the statistics. We have society to blame for this; the gender roles prescribed to males can make them feel like seeking help is a sign of weakness. Historically, soldiers who were diagnosed with PTSD were discharged from the military because of this very perception. Women are also expected to be more emotional, or “hysterical,” making it easy for a doctor to misdiagnose their symptoms, based solely on what is perceived as normal or acceptable behavior.

The types of traumatic exposure play a large role in addressing the gender divide. Therapist Nicole Amesbury said, “Gender division can be seen in PTSD and BPD in the presentation, comorbidity, and types of trauma exposure. There are differences in the type of trauma exposure that men and women experience. For example, rape carries one of the highest risks for developing PTSD and only .7% of men report rape, as opposed to 9.2% of women in the United States. Because the genders present with differing trauma — and rape occurs more to women and is underreported by men — we see societal differences in gender that create a division in diagnosis. Even whether or not someone will seek help aligns along this gendered division.”

Amesbury went on to say, “In addition, men and women present symptoms differently. In both PTSD and BPD men are more likely to present with irritability, impulsivity, explosive aggression and/or a comorbidity of substance abuse disorders, while women are more likely to show emotional numbing, self-harm behaviors, and/or a comorbidity of eating disorders.”

If men, particularly soldiers — who are just as likely to exhibit symptoms of BPD as women — are instead given the incorrect diagnosis of PTSD, the scope of treatments becomes limited.

Similarly, women who have PTSD and are diagnosed with BPD may not receive an effective treatment plan. This, of course, doesn’t address the fact that BPD and PTSD sometimes go hand in hand — having one diagnosis when both are present creates a dichotomy that can leave the condition wholly untreated.

The importance of an accurate diagnosis not based on gender is critical. The path to getting there, however, may not be as simple.

First, we, as a culture, must stop using language and stereotypes that presents females as hysterical, emotional beings who are socialized toward co-dependency. We need to dismantle the stereotype that men are supposed to be strong and shouldn’t need to ask for help, as well as the notion that they don’t show their emotions (but, somehow tend toward anger more than women).

Second, doctors and psychiatrists must eliminate the idea of gender from their methods of diagnosis. It simply shouldn’t be a factor when there are entire criteria guidelines that can be applied, instead.

Diagnosis based on gender is harmful and decreases the likelihood that men and women, alike, will receive the treatment they need.

I would love to hear from you so please leave a comment. All feedback is much appreciated. Thank you. Erin