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Borderline Personality Disorder in Men Overlooked, Misdiagnosed
This article originally appeared in my Stop Walking on Eggshells blog on Psychology Today.
I often get letters from readers asking for help. This one was different. It carried a stamp warning me it was from a prisoner. The handwritten letter inside was a plea for help from a man in the penal system with borderline disorder. Later, I found out that he had written many of my fellow BPD advocates looking for help. That letter really brought it home for me that men have BPD too. Only the outlook for them is bleaker. They are much less likely to get help because of gender bias and ignorance.
What do we know about men with BPD? The latest research shows that indeed the gender split is not 75% female, 25% male as is stated in the DSM-IV. The prevalence is nearly 50/50. We have a long way to go until we know how to diagnose and treat borderline men.
The following article is from my book The Essential Family Guide to Borderline Personality Disorder.
Here are some reasons why BPD in men is overlooked and why we know so little about borderline men.
Men seek professional help less often
Research has shown again and again that men won't even seek treatment for less complex but equally serious mental health problems such as depression, let alone a stigmatized disorder like BPD that calls their whole personality into question. Many men see it as "unmanly" to acknowledge feelings, especially the vulnerability and abandonment fears associated with BPD. Since fewer men seek treatment, they are not available candidates for research.
One study found that when 52 professionals from a mental health agency in California assessed patient vignettes, they were unable to accurately diagnose the presence of BPD in males--even though the symptoms were identical to those in vignettes of females.
This results, in part, in the way anger is interpreted differently depending upon whether it comes from a man or a woman. "For the most part, when women are angry they are classified as irrational, frenzied, or too emotional," says therapist Andrea Brandt. "On the other hand, men's anger is sometimes recognized as strength and aggressiveness."
Men are socialized not to expose their fear of abandonment or other emotional vulnerabilities, which are hallmarks of BPD. They are supposed to be macho and fearless, sexual studs seeking the maximum number of sexual conquests with a minimum of commitment. And if he does get "roped" into marriage, he's the one who's supposed to be on top, for fear of being called "whipped."
Most of all, if he's not as confident as he "should" be, or if he's feeling alone, depressed, or scared, by the Male Code he is not supposed to let these feelings show. He is, however, permitted anger. In some circumstances, beating someone up is even the righteous thing to do.
Imagine you're a man whose greatest fear in the world is being abandoned, second only to the terror of looking into the mirror and seeing an empty, worthless self looking back. Imagine how hard it would be to share these emotions with the people you're scared will reject you, let alone to admit you need professional help.
Those feeling have to go somewhere. Some men use the same outlets as borderline women do, such as making suicide threats. A great many of them (even more than women) anesthetize themselves with alcohol and harder drugs such as cocaine or methamphetamine. A subset, however, channel their feelings into their more socially acceptable cousins, rage and aggression.
Rex Cowdry, MD, the former acting deputy director of the National Institute of National Health, says, "A hallmark trait of BPD, the inability to manage inner feelings, is just as present in the male population, but is often exhibited in spousal abuse or other violent acts rather than the self-directed anger more often seen in women."
Both men and women can express their fear of abandonment as physically aggressive rage toward the "cause" of their distress. However, men's level of violence is more lethal. A perceived betrayal or a real or imagined act of abandonment may trigger acting out activities such as kicking down a door, forcing sexual activity, blocking the partner's escape, and threatening the partner with a weapon. Some are involved in controlling and stalking behaviors such as bugging phones, installing secret cameras, and hiring private detectives.
This aggression often results in a misdiagnosis of antisocial personality disorder (sociopath) or, in adolescents, a conduct disorder. As a result, they don't get the right treatment. What they do get is incarcerated. As a matter of fact, so many males with BPD have been incarcerated that a form of therapy for BPs, Dialectical Behavior Therapy, has been adapted for male offenders in correctional settings.
How do borderline men differ from women?
Therapist Mary Gay, who treats many men with BPD, says she finds that borderline men frequently engage in addictive, sexually compulsive behaviors, including regularly hiring of prostitutes, having serial affairs, going to strip clubs, obsessively viewing pornography, engaging in voyeurism or exhibitionism, and compulsive masturbation. One borderline man used high-risk sex as his form of self-harm. He says:
The out-of-control sex was something I hated myself for, it was obsessive, it felt like an invisible hand grabbing me by the collar and dragging me off to do whatever. I needed to cause enough pain and degradation to myself. The incredible guilt of the risks I was exposing my partner to really destroyed something inside me. But when the inner loneliness was strongest, sex was the only thing that would quiet the fear.
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