Are There Gender Differences in Borderline Personality Disorder?

Summary: Yes, there are gender differences borderline personality disorder (BPD). A new study shows gender differences in borderline personality disorder related to diagnosis, patient temperament, co-occurring diagnoses, brain activity, and utilization of treatment.

Key Points:

• Borderline personality disorder is a serious mental illness with symptoms that cause severe disruption across core life domains.
• Previous research shows conflicting – and at times completely opposite/contradictory – results related to gender differences in borderline personality disorder
• Different outcomes related to prevalence, symptom presentation, and treatment create an unclear picture of gender differences in BPD

Treating Borderline Personality Disorder (BPD)

Before the turn of the millennium, many therapists avoided treating patients with borderline personality disorder because of its complexity and widespread misunderstandings about the nature of the disorder among treatment professionals.

In recent years, though, as the science behind treatment advances, stigma around personality disorders decreases, and understanding about the nature and course of the disorder expands, mental health experts have identified effective therapeutic approaches to BPD beyond the ineffective, medicate and forget approach common in the treatment community before the paradigm shift that began in the 1980s reached fruition and changed the way we view and treat mental illness.

Now, in the 21^st century, the treatment community no longer fears the diagnosis, and more treatment centers accept patients with BPD. But there’s a significant amount of conflicting information about BPD in the existing research, particularly around gender differences in borderline personality disorder.

Before we look at a new study on those differences, we’ll take a moment to advocate for BPD treatment. Interviewed in an article published by the American Counseling Association, professional counselor Rose Skeeters, diagnosed with BPD in her early 20s, observes:

“BPD doesn’t just have a stigma in society; it’s in our profession too. It’s a diagnosis that is seriously misunderstood, and the mind of someone with borderline personality isn’t empathized with enough. There are clients out there struggling with this who need our help.”

Skeeters continues with insight gained from personal experience, both as a patient with BPD and a provider with experience treating patients with BPD:

“The biggest misconception about borderline personality is that it isn’t treatable. It may be difficult to treat because emotions can rev up from 0 to 60 very quickly for someone with BPD, and in those moments, the logic of reality just isn’t there for that person. But this is not a life sentence and it’s not hopeless to get better. With proper treatment, clients can become self-aware and recover.”

That last sentence is what we want people with BPD – and their friends and families – to understand: with evidence-based treatment, recovery is possible. With that said, we’ll shift our focus back to the specific aspects of BPD we discuss in the introduction to this article, above.

New Research on Gender Differences in Borderline Personality Disorder

In early 2024, a groups of researchers based at the University of Turin published a study called “Gender Differences in Borderline Personality Disorder: A Narrative Review.” The research team identified this goal:

“To provide an updated overview of the differences among genders in BPD in terms of diagnosis, temperamental and clinical characteristics, comorbidities, findings of neuroimaging, and treatment attitudes.”

To review and understand the gender differences in the various aspects of BPD they list, the research team collected and examined data from 46 studies including information on 34,653 patients between the ages of 11 and 90 with a clinical diagnosis of BPD.

Here’s the conflicting evidence around gender and borderline personality we mention above that serve as the impetus for conducting this review:

• Traditional estimates indicate that among all people with BPD:
  • 75% are women
  • 25% are men

However, more recent research tells a different story:

• A recent study published in the U.S. showed the following population-level rates of BPD:
  • Men: 5.4%
  • Women: 5.2%
• A study published in Norway showed the following population-level rates of BPD:
  • Men: 0.4%
  • Women: 0.9%
• And a study published in the United Kingdom (U.K.) showed the following population-level rates of BPD:
  • Men: 1.0%
  • Women: 0.4%

Now that we understand why an in-depth examination of the gender differences in borderline personality disorder is necessary, let’s take a look at what the researchers found.

Gender Differences in Borderline Personality Disorder: Outcomes

To review, the research team defines BPD as follows:

“BPD is a complex and heterogeneous mental disease characterized by a pattern of identity diffusion, interpersonal instability, and chronic feeling of emptiness, with episodes of severe affective and impulsive dyscontrol.”

In this context, heterogenous means BPD manifests in a variety of different ways, depending on the individual, their history, and their current circumstances.

Experts identify nine primary symptoms of BPD:

1. Extreme efforts to avoid abandonment
2. Unstable peer and family relationships.
3. Risky and/or impulsive behavior
4. Unstable, inconsistent, distorted image of self
5. Suicidality and or self-harm behavior
6. Severe mood swings
7. Persistent feelings of emptiness
8. Intense, uncontrollable anger
9. Persistent feelings of dissociation and/or paranoia

The research team examined existing research for evidence related to gender differences in five aspects of BPD: diagnosis, patient temperament, comorbidities/co-occurring disorders, results of neuroimaging with MRI/fMRI, and treatment utilization.

We’ll share the results for each of these aspects of BPD now.

Borderline Personality Disorder: Gender Differences

Diagnostic Differences:

• Men were more likely to report the following symptoms:
  • Anger, e.g. intense and inappropriate anger
  • Behavioral control problems, e.g. impulsivity
• Women more likely to report the following symptoms:
  • Depressive states, e.g. chronic feelings of emptiness
  • Mood changes, e.g. affective instability
  • Suicidality, e.g. suicidal ideation, suicide plans, self-harm

Differences in Patient Temperament:

• Men were more likely to:
  • Show greater affinity for the trait novelty seeking
  • Engage in self-harm behaviors
  • Display impulsive behavior
  • Experience outbursts of anger
• Women were more likely to:
  • Show a higher degree of affective instability
  • Display identity disturbance
  • Experience chronic feelings of emptiness
  • Report unstable relationships

Differences in Comorbidities/Co-Occurring Disorders:

• Compared to women, men were more likely to:
  • Have diagnosis of antisocial personality disorder
  • Have diagnosis of substance use disorder

Neuroimaging:

• During tasks that elicited anger, researchers observed minor gender differences in activity in the following brain areas:
  • Prefrontal cortex
  • Striatum
  • Amygdala

These findings notwithstanding, there are too few studies comparing neuroimaging results in male and female subjects with BPD to draw definitive conclusions.

Treatment Utilization:

• Researchers found no significant differences in rates of treatment utilization

Treatment Type:

• Men:
  • Received drug/alcohol treatment more often than women
• Women:
  • Engaged in psychotherapy more often than men
  • Received pharmacotherapeutic interventions more often than men

We’ll discuss these results below.

What Did We Learn? Men, Women, and Borderline Personality Disorder (BPD)

The researchers did not attempt to explain the differences in prevalence rates reported in previous research, but they did explore factors that could skew diagnosis based on the gender of the patient and the preconceptions of the assessing clinician. These factors include presence of anger and impulsivity in men, and affective instability, chronic emptiness, and suicidality in females.

Current diagnostic criteria for BPD overlap significantly with disorders such as anxiety, depression, and bipolar disorder, which makes misdiagnosis and/or underdiagnosis of BPD – compared to those more common disorders – more likely.

This research and these results help most by reminding clinicians that diagnosis and treatment of BPD is continuously evolving and improving. The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), represents a significant change in the way clinicians diagnose BPD, which may reduce misdiagnosis, while the dimensional approach recently established by the International Classification of Diseases, 11^th Edition (ICD-11) may further improve overall diagnostic accuracy.

When we review and evaluate patients for mental health disorders with symptoms that overlap with BPD, we need to remind ourselves of exactly that. We can fine-tune our diagnostic skills to include the information above, and understand that while men and women may present symptoms in dramatically different ways and require different treatment approaches, the underlying diagnosis may be the same: borderline personality disorder.