By way of Elaine, I discovered that today is Blogging Against Disablism Day. (There are so many blog against/blog for/blog about days, it’s hard to keep track. Anyone know of a roundup or a calendar something? Similar to The Truth Laid Bare’s Ubercarnival? Which has been giving me a database error like forevah? Anyones?)
Initially, when Elaine mentioned Blogging Against Disablism Day, I wasn’t planning on participating; not because it’s an issue I don’t care about, but because I wasn’t sure what I might contribute to the conversation. In today’s post, Elaine discusses mental disability, more specifically, depression, generalized anxiety disorder and borderline personality disorder, which got me thinking.
As an undergrad, I majored in psychology (I know, *groan* – not another one of those human resources assholes. But I was *serious* about my classes, dammit!) and, aside from the required courses, was given some degree of latitude in my psych studies. Between my psych major and my honors classes, I was even allowed to earn six credits through independent study projects – two fairly comprehensive literature reviews, one of social anxiety disorder (“The Identification and Etiology of Social Phobia”) and another on personality disorders (“Assessing Axis II: Issues & Controversies Surrounding Personality Disorder Diagnoses”). Even cooler, the lone clinical psychology professor at my college was also heavy into women’s studies, so I was able to take several of her courses – while she supervised my projects. As a result, one semester I had the opportunity to tackle the same topic for two different classes, both with my totally awesome feminist prof.
So my last semester of college, I literally spent half my time researching and critiquing personality disorders – categorical vs. continuum models, the Axis I/II distinction, problems with diagnostic instruments and criteria, the biased application of personality disorder diagnoses, etc. By far the most fascinating topic – perhaps because I was simultaneously taking my first and only women’s studies course, Psychology & Women – is the amount of gender bias inherent in Axis II diagnoses. That is, in most of the personality disorder labels.
For my contribution to Blogging Against Disablism Day, I thought I might excerpt a portion of “Sex & Gender Bias in Personality Disorder Diagnoses” (2001 – my, how I date myself!), my final paper for the Psychology & Women course. Why, you ask? Well, it’s important to recognize that the psychiatric and medical communities are just like any other, warts and all; even supposedly objective professionals bring personal agendas and biases to the table. These color both the research and application of mental disorders and their diagnoses, such that a seemingly scientific condition such as depression can serve to reinforce (or enforce) gender roles. In the past, the DSM identified homosexuality as a mental disorder, and in the ’50s, lobotomies came into favor with the families of women who did not, or could not, fulfill their gender roles satisfactorily. In short, medical professionals don’t always operate with the patient’s best interests in mind.
While there are a number of ways in which personality disorders reflect sex and gender bias, tonight I’ll focus on the criteria itself. The very symptoms one must exhibit to “earn” a personality disorder diagnosis oftentimes reflect gender roles, such that a woman (or man) who conforms too closely to her or his stereotyped gender role may be diagnosed with a personality disorder.
Sex & Gender Bias in Personality Disorder Diagnoses -> Biased Personality Disorder Criteria
Perhaps the most fundamental form of gender bias in regards to personality disorders is bias in the constructs themselves (Widiger, 1998). Biased application and use of personality disorder labels may merely be a consequence of biased personality disorder constructs. For instance, it may very well be the differences at the criterion level that results in differential diagnostic rates among personality disorders such as antisocial personality disorder (Rutherford, Alterman, Cacciola, & Snider, 1995). Biased constructs would include those which are sexist characterizations of females or of the “feminine gender” (Widiger, 1998) – or of males or the male gender, for that matter. A specific criterion can be singled out as biased if it does not truly reflect dysfunction, or if it can be applied to one sex more than the other, resulting in false positives (Lindsay, Sankis, & Widiger, 2000; Widiger, 1998). Unfortunately, biased constructs are potentially the most difficult problems to address.
A close examination at the DSM-IV (American Psychiatric Association, 1994) criteria for the ten official personality disorders (i.e., paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive) turns up a number of criteria that seem to meet Lindsay, Sankis, and Widiger (2000) and Widiger’s (1998) conditions for sex and/or gender bias. This prejudice can be found not only in disorders that are biased towards females, but towards men as well.
For instance, among the criteria for borderline personality disorder are “frantic efforts to avoid real or imagined abandonment”, “identity disturbance”, “impulsivity in…spending, sex, substance abuse, reckless driving, [and/or] binge eating”, “affective instability”, “chronic feelings of emptiness”, and “inappropriate, intense anger or difficulty controlling anger”. One must display the following to be diagnosed with histrionic personality disorder: “inappropriate sexually seductive or provocative behavior” when interacting with others; a sense of discomfort “in situations in which he or she is not the center of attention”; the consistent use of “physical appearance to draw attention to the self”; “self-dramatization, theatricality, and exaggerated expression of emotion”; suggestibility; and the belief that relationships are “more intimate than they actually are”. Moreover, dependent personality disorder (discussed in detail below), a personality disorder characterized by “a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation”, is possibly the personality disorder most representative of the traditionally feminine woman.
The criteria for borderline, histrionic, and dependent personality disorder all seemingly display sex bias. Above all else, these criteria can certainly be applied to women at a higher rate than men. The female gender role dictates that women should be more invested in personal relationships, and thus it follows that women would also fear and try to avoid abandonment more “frantically” than men. Females have largely been relegated to the home so that they may raise children, which is not necessarily fulfilling to all women; so of course women, more oftentimes than men, would experience “identity disturbances” and “chronic feelings of emptiness”. Because of their continued oppression, it should not be surprising that women experience “intense anger”; yet, when does said anger become “inappropriate”, and by whose determination? Stereotypically, sexuality is considered females’ largest source of power over men. Due to feminine socialization that reflect such attitudes, it would not be surprising if women, to a higher degree than men, used “physical appearance to draw attention to the self” and display “inappropriate sexually seductive or provocative behavior” in their interpersonal interactions. Furthermore, the “impulsive” behaviors referred to in the borderline criteria are largely stereotypically feminine behaviors (i.e., shopping, binge eating, and promiscuity).
Neither are all of these behaviors, in and of themselves, are maladaptive. “Frantic efforts to avoid abandonment” is a rather vague criterion. How exactly is “frantic” defined, and by whom? What may seem like desperate attempts to prolong a relationship to one person, may be intended as survival tactics by the person in question. In other words, since men, as a whole, are not dependent upon females for their economic well being, they may mislabel women’s efforts to stay with romantic partners whom they rely on financially as motivated by fears of abandonment as opposed to fears of poverty. Thus, their attempts to stay in relationships may be seen as “frantic” efforts to avoid rejection or abandonment, rather than more practical attempts to avoid poverty. The main concern in reference to the maladaptivity of certain criteria seems to be, in whose opinion is the behavior maladaptive? While many Axis I criteria are rather straightforward on this subject (for instance, who can deny that the criteria for schizophrenia are maladaptive?), Axis II criteria entail more of a judgment call – one ultimately made by the DSM task force and practicing psychiatrists, a majority of which are middle-aged white males (Widiger, 1998).
Conversely, some personality disorders closely mirror the traditional male gender role (American Psychiatric Association, 1994). The criteria for schizoid personality disorder include “almost always chooses solitary activities”; “lacks close friends or confidants other than first-degree relatives”; and “emotional coldness, detachment, or flattened affectivity”, which are all in some way reflective of the Western definition of masculinity. The criteria for narcissistic personality disorder are even more dubious. Those with narcissistic personality disorder have a “grandiose sense of self-importance”, are “preoccupied with fantasies of unlimited success, power, [and] brilliance”, believe that they are “special and unique”, require “excessive admiration”, have a “sense of entitlement”, are “interpersonally exploitive”, lack empathy, and show “arrogant, haughty behaviors or attitudes”. Perhaps the personality disorder most reminiscent of the male gender role is antisocial personality disorder (discussed in detail below), which is exemplified by “a pervasive pattern of disregard for, and violation of, the rights of others”.
These criteria for male-typed personality disorders also appear to reflect sex bias. Schizoid personality disorder mainly comprises emotional and interpersonal distance – a main component of the male gender role. Narcissistic personality disorder seems to complement schizoid, in that it entails extreme ambition, arrogance, and a sense of entitlement. Along with antisocial personality disorder, the three disorders seem to embody the Western definition of masculinity. Not all of these criteria are necessarily maladaptive, either. For instance, ambition, success, brilliance, and independence are especially valued in today’s society.
Most critics of gender bias in the DSM point to how disorders pathologize traditionally feminine characteristics and behaviors. Yet, bias in personality disorder diagnoses seems to exist against both males and females. Some evidence even suggests that men are more oftentimes the victims of gender bias. For instance, it’s been found that, of the 76 items on popular personality disorder inventories that appear to reflect sex or gender bias, 80% were centered around traditionally masculine characteristics (Widiger, 1998). Still, many critics claim that women are in fact the victims of bias in regards to personality disorders. The answer to this question may lie in how clinicians apply the personality disorder diagnoses.
Ooooh, a cliffhanger! Stay tuned, and maybe I’ll post the next section, “Bias In the Application of Personality Disorders” on the
Third (?) Fourth Annual Blogging Against Disablism Day.
Until then, here’s the complete reference list, since I don’t feel like going through and picking out the articles and books not cited in the above section.
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