tag:theconversation.com,2011:/id/topics/borderline-personality-disorder-5304/articlesBorderline personality disorder – The Conversation2023-03-20T19:23:28Ztag:theconversation.com,2011:article/1992112023-03-20T19:23:28Z2023-03-20T19:23:28ZGirl, Interrupted interrogates how women are ‘mad’ when they refuse to conform – 30 years on, this memoir is still important<figure><img src="https://images.theconversation.com/files/511307/original/file-20230221-28-pq60te.jpeg?ixlib=rb-1.1.0&rect=0%2C1%2C1024%2C573&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Winona Ryder played Susannah Kaysen in the film of Kaysen's memoir, Girl, Interrupted</span> <span class="attribution"><span class="source">Columbia Pictures/IMDB</span></span></figcaption></figure><p>Thirty years ago, American writer Susanna Kaysen published her memoir <a href="https://www.hachette.com.au/susanna-kaysen/girl-interrupted">Girl, Interrupted</a>. It tells the story of her two years inside McLean Hospital in Boston as a psychiatric patient. </p>
<p>She was admitted, aged 18, in 1967. A few months earlier, she had taken 50 aspirin in a state of despair. Late in the book, she reveals she had a sexual relationship with her male English teacher at school. </p>
<p>Kaysen was interviewed briefly by a doctor before she was admitted as a “voluntary” patient: a legal category used to indicate a person’s status in the institution. Despite what the term implies, “voluntary” doesn’t mean a patient can leave without the consent of their medical team, as Kaysen explains. People admitted as voluntary patients acknowledge their own need for treatment. </p>
<p>During Kaysen’s stay, she was treated with an <a href="https://theconversation.com/story-of-antipsychotics-is-one-of-myth-and-misrepresentation-18306">antipsychotic</a> medication, chlorpromazine, and received psychotherapy. In her memoir, the stories of other young women confined with her at McLean convey sympathetic and recognisable experiences of the institutional world and its regime.</p>
<p>Girl, Interrupted is one of the most famous memoirs of hospitalisation and mental illness. More <a href="https://www.euppublishing.com/doi/abs/10.3366/ircl.2019.0310?journalCode=ircl">recent interpretations</a> describe it as a narrative of “trauma”. </p>
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<span class="caption">Susanna Kaysen was admitted as a ‘voluntary’ psychiatric patient aged 18, in 1967. She wrote about her experience in Girl, Interrupted.</span>
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Read more:
<a href="https://theconversation.com/how-can-publishers-support-the-authors-of-trauma-memoirs-as-they-unpack-their-pain-for-the-public-new-research-investigates-189251">How can publishers support the authors of trauma memoirs, as they unpack their pain for the public? New research investigates</a>
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<h2>‘Mad’ or refusing to conform?</h2>
<p>Kaysen did not anticipate the book’s reception at the time of its publication in 1993. It seemed to open readers up to tell their own stories, and they wrote to her from many places around the world to tell her about their hospitalisation. Looking back in a new edition published this year by Virago Books, she writes “it was surprising to me how many people had been in a mental hospital or had what used to be called a nervous breakdown”. </p>
<p>When it appeared, her book was widely reviewed as “funny”, “wry”, “piercing” and “frightening”. Set out as a series of short vignettes, the book allowed readers the space to “insert themselves” into this story of human suffering. </p>
<p>Investigating whether she had ever really been “crazy” – or just caught up in an oppressive approach to girls whose lives strayed from expectations – likely meant possible personal exposure, admission of frailty, and fear of judgement for Kaysen. </p>
<p>Thirty years later, we have better understandings of trauma and of care for people with mental illness. So what can this book tell us now?</p>
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<p>Kaysen had waited almost three decades after these experiences before sharing her story in the early 1990s. This may be one reason it resonated with readers. The book was published at a time when most large institutions had closed as part of a worldwide trend towards deinstitutionalisation. Many people were starting to talk more openly about their own episodes of mental illness and recalling periods of hospitalisation that were sometimes grim and harrowing. </p>
<p>By the 1990s, there was also much greater awareness of the uneven power relationships in psychiatric treatment. Women and girls, subject to gendered social expectations, have historically received different forms of medical and psychiatric treatment. Women have been described as “mad” for centuries when they refused to conform to gender norms.</p>
<p>The book – an account of adolescent turmoil, with girlhood at the centre – can tell us about the lived experiences of teenage girls who face interior struggles over their mental health and wellbeing. Published in 1993 about the events of the late 60s, its insights are enduringly relevant.</p>
<h2>A controversial diagnosis</h2>
<p>In 1993, The New York Times ran an article titled “<a href="https://www.nytimes.com/1993/06/20/books/a-designated-crazy.html">A Designated Crazy</a>” that explained Kaysen had hired a lawyer to access her patient clinical records, 25 years after being at McLean. These appear in the book.</p>
<p>Placed at intervals in the narrative, these notes show the objectifying medical practices of admission, collecting information and establishing a diagnosis. The information in these clinical pages is deeply personal. Sharing them is an act of resistance and defiance.</p>
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<p>“Needed McLean for [the past] 3 years”<br>
“Profoundly depressed – suicidal”<br>
“Promiscuous … might get herself pregnant”<br>
“Ran away from home”<br>
“Living in a boarding house”<br></p>
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<p>Kaysen’s father, an academic at Princeton, wrote these notes in April 1967.</p>
<p>In June 1967, the formal medical notes from her admitting doctor stated she had “a chaotic and unplanned life”, was sleeping badly, was immersed in “fantasy” and was isolated.</p>
<p>Kaysen was admitted as “depressed”, “suicidal” and “schizophrenic”, with “borderline personality disorder”. </p>
<p>While the psychiatric diagnoses used in the 1960s still exist, the borderline diagnosis is <a href="https://theconversation.com/borderline-personality-disorder-is-a-hurtful-label-for-real-suffering-time-we-changed-it-41760">now controversial</a>. Progressive psychologists and feminist psychologists are more likely to use the term “complex trauma”. Some of the other young women in the memoir had traumatic life experiences of sexual abuse and violence, which manifested as <a href="https://theconversation.com/how-many-people-have-eating-disorders-we-dont-really-know-and-thats-a-worry-121938">eating disorders</a> and <a href="https://theconversation.com/explainer-what-is-self-harm-and-why-do-people-do-it-11367">self harm</a>.</p>
<p>Diagnostic labels have evolved over time. The first edition of the <a href="https://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568">Diagnostic and Statistical Manual</a> (DSM) was published in 1952. In 1967, the year of Kaysen’s committal, the DSM did not include “borderline personality disorder”, though the borderline concept had been <a href="https://www.press.jhu.edu/newsroom/dsm-history-psychiatrys-bible">theorised from the 1940s.</a> </p>
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Read more:
<a href="https://theconversation.com/borderline-personality-disorder-is-a-hurtful-label-for-real-suffering-time-we-changed-it-41760">Borderline personality disorder is a hurtful label for real suffering – time we changed it</a>
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<h2>McLean’s famous patients</h2>
<p>We can also read the book as an exposé of the controlling world of psychiatric institutions for people in the 1960s. The vast majority of people with psychiatric conditions were confined in public institutions, in often overcrowded conditions. Abuses happened, and violence was common.</p>
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<span class="caption">John Forbes Nash, whose life inspired the film A Beautiful Mind, was also a McLean patient.</span>
<span class="attribution"><span class="source">Peter Badge</span></span>
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<p>One distinction for those hospitalised at McLean in Boston, a private institution, was that it housed people whose families could afford the steep fees. Kaysen’s father had to declare his salary when he signed the paperwork. Famous patients included the mathematician <a href="https://theconversation.com/the-legacy-of-john-nash-and-his-equilibrium-theory-42343">John Forbes Nash</a> (whose story was told in the film, <a href="https://www.imdb.com/title/tt0268978/">A Beautiful Mind</a>), and New England poets Robert Lowell and <a href="https://theconversation.com/60-years-since-sylvia-plaths-death-why-modern-poets-cant-help-but-write-after-sylvia-199477">Sylvia Plath</a> in the late 1950s.</p>
<p>McLean’s own “biography” is the subject of another book. <a href="https://www.theatlantic.com/magazine/archive/2002/01/the-asylum-on-the-hill/303058/">Gracefully Insane</a> shows its reputation as housing sometimes idiosyncratic and wealthy people whose families wanted them to be hidden, fearful of the stigma of mental illness in the family.</p>
<p>Plath’s <a href="https://www.allenandunwin.com/browse/book/Sylvia-Plath-Bell-Jar-9780571268863">The Bell Jar</a> fictionalises her hospitalisation at McLean in the 1950s, following a suicide attempt. </p>
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<p>Doctor Gordon’s private hospital crowned a grassy rise at the end of a long, secluded drive that had been whitened with broken quahog shells. The yellow clapboard walls of the large house, with its encircling verandah, gleamed in the sun, but no people strolled on the green dome of the lawn.</p>
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<p>Like Kaysen, Plath’s character Esther Greenwood has been involved in sexual relationships with men that made her uneasy, affecting her confidence and sense of self. Skiing with Buddy Willard, she falls and breaks her leg: “you were doing fine”, someone says, “until that man stepped into your path”. </p>
<p>Later, floundering at college, she too is admitted by a male doctor acting on the advice of her mother: she has not slept, she is exhausted, she is not herself. He advises she needs shock therapy.</p>
<p>In her new biography of Plath, <a href="https://www.penguin.com.au/books/red-comet-9781529113143">Red Comet</a>, Heather Clark describes McLean in the 1950s as reliant on shock therapy and activities, rather than psychoanalysis and careful therapeutic interventions. It was reputedly only a “notch above” a public institution, though it had the veneer of being for elite residents.</p>
<p>Just a few years before Kaysen’s admission to McLean, Plath died by suicide in 1963, aged 30. The Bell Jar had been published one month earlier, under a pseudonym. By the late 1960s, teenage admissions were a focus for McLean’s doctors. </p>
<p>Did adolesence present a new challenge for families and authorities, making young women vulnerable to institutionalisation?</p>
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<span class="caption">McLean Hospital’s famous patients included Sylvia Plath and Robert Lowell, as well as John Forbes Nash and Susanna Kaysen.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
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Read more:
<a href="https://theconversation.com/by-naming-pennhurst-stranger-things-uses-disability-trauma-for-entertainment-dark-tourism-and-asylum-tours-do-too-185581">By naming 'Pennhurst', Stranger Things uses disability trauma for entertainment. Dark tourism and asylum tours do too</a>
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<h2>Psychiatry and romantic love</h2>
<p>Revisiting Girl, Interrupted, I am struck by its raw and honest recognition of the way women have sometimes experienced relationships with men as inherently oppressive. The structures of psychiatry and romantic love intersect throughout this book. </p>
<p>Kaysen, like Plath, sees the family as a toxic institution. Male psychiatrists loom over both women, imposing in their authority to diagnose. “He looked triumphant”, wrote Kaysen of her doctor. “Doctor Gordon cradled his pencil like a slim, silver bullet”, wrote Plath.</p>
<p>Women writing about their own madness has a long history. American writer Charlotte Perkins Gilman (1860–1935) penned the story <a href="https://www.goodreads.com/book/show/286957.The_Yellow_Wall_Paper">The Yellow Wallpaper</a> in The New England Magazine in 1892. It <a href="https://www.theguardian.com/artanddesign/2020/feb/07/charlotte-perkins-gilman-yellow-wallpaper-strangeness-classic-short-story-exhibition">tells the tale</a> of a woman’s mental and physical exhaustion following childbirth.</p>
<p>Historians such as Elizabeth Lunbeck <a href="https://press.princeton.edu/books/paperback/9780691025841/the-psychiatric-persuasion">write about</a> the way a “psychiatric persuasion” came to dominate thinking about gender in the early 20th century. Psychiatrists began to see everyday life difficulties – such as the changes experienced during adolescence – as signalling illness (we might say, pathologising “normal” responses to stressful events). The rise of psychiatric expertise paralleled their professional reactions to women (and men) who struggled with life.</p>
<p>In Australia, the history of “good and mad women” up to the 1970s by <a href="https://books.google.com.au/books/about/Good_and_Mad_Women.html?id=NIZ9QgAACAAJ&redir_esc=y">Jill Julius Matthews</a> showed that women who experienced hospitalisation as a result of mental breakdown were perceived as having “failed” to meet the gendered expectations of them. Femininity and its constraints left some women unable to function or live authentic lives.</p>
<h2>Institutions on film</h2>
<p>Girl, Interrupted was released <a href="https://www.imdb.com/title/tt0172493/">as a film</a> by Columbia Pictures in 1999, with a cast of rising and established young actors, including Winona Ryder, Angelina Jolie and Brittany Murphy. It dramatised the interpersonal relationships inside the hospital described by Kaysen.</p>
<p>The film script was not only the perfect vehicle for an ensemble cast of these women. It was also another opportunity to make mental illness visible on the screen. Another page-to-screen adaptation in 1975, Milos Forman’s film of Ken Kesey’s <a href="https://www.imdb.com/title/tt0073486/">One Flew Over the Cuckoo’s Nest</a>, brought to life the dramatic environment of institutional control and violence personified by the character of Nurse Ratched. </p>
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<figcaption><span class="caption">Girl, Interrupted, like One Flew Over the Cuckoo’s Nest, emphasised resistance to institutional control.</span></figcaption>
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<p>Girl, Interrupted’s screenplay surfaced different women’s experiences of abuse, neglect, trauma and violence to explain their behaviours and responses to institutional constraints. </p>
<p>Like One Flew Over the Cuckoo’s Nest, the film also emphasised the theme of resistance to institutional control. Patients hid pill medications under the tongue, broke into the hospital administration office to look at their case files, and found ways to circumvent the routines of institutional life. The film depicted the drama of group therapy, and the power dynamic between staff and patients.</p>
<p>Not everyone who was institutionalised reacted the same way to being in hospital.</p>
<p>Kaysen wrote:</p>
<blockquote>
<p>For many of us, the hospital was as much a refuge as it was a prison. Though we were cut off from the world and all the trouble we enjoyed stirring up out there, we were also cut off from the demands and expectations that had driven us crazy.</p>
</blockquote>
<p>A recent collaborative history of institutional care by Australian poet <a href="https://theconversation.com/secrecy-psychosis-and-difficult-change-these-lived-experiences-of-mental-illness-will-inspire-a-kaleidoscope-of-emotions-191011">Sandy Jeffs</a> and social worker Margaret Leggatt, <a href="https://podcasts.apple.com/am/podcast/out-of-the-madhouse-with-sandy-jeffs/id992762253?i=1000501765764">Out of the Madhouse</a>, challenges the idea of the institution as a place of alienation. Jeffs found community and solace at Larundel Hospital in Melbourne in the late 1970s and 1980s. However, the book also acknowledges this is not a universal response for institutionalised people.</p>
<p>Like Kaysen, people with lived experiences of mental illness and hospitalisation have found it therapeutic to write about their personal challenges. For some, it provides an opportunity to embrace the “mad” identity, to find empathy for others. And to create a new self out of the chaos of mental breakdown.</p><img src="https://counter.theconversation.com/content/199211/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catharine Coleborne received funding from the Australian Research Council as a CI on a relevant Discovery Grant, 'The development of Australian community psychiatry’ (2019-2022).</span></em></p>Why was Susanna Kaysen really hospitalised? Her memoir Girl, Interrupted turns 30 this year. It investigates whether she was ‘mad’, or medicalised for a ‘chaotic’ life that defied gender norms.Catharine Coleborne, Professor of History, School Humanities, Creative Industries and Social Sciences, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1630352021-06-29T12:42:48Z2021-06-29T12:42:48ZMany of us feel ‘empty’ – understanding what it means is important for improving our mental health<figure><img src="https://images.theconversation.com/files/408839/original/file-20210629-17-71tye3.jpg?ixlib=rb-1.1.0&rect=7%2C14%2C4937%2C3276&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many of us may have described feeling 'empty' before.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/thoughtful-girl-sitting-on-sill-embracing-793940824">fizkes/ Shutterstock</a></span></figcaption></figure><p>It’s likely you have felt “empty” at some point in your life – or perhaps you’ve heard someone else describe themselves in that way. But while this might be a relatively common feeling, it’s often not spoken about as a symptom of mental health difficulties. Typically, “feelings of emptiness” are only considered as a symptom of borderline personality disorder – a mental health condition characterised by challenges with emotions, relationships to others, and feelings of chronic emptiness.</p>
<p>But, after coming across many people who reported “feeling empty” when accessing mental health services in Scotland, our research team wanted to know more about the feeling, which was rarely mentioned in mental health research. We began asking the people we interviewed whether they had ever felt this way.</p>
<p>This began a <a href="https://www.tandfonline.com/doi/full/10.1080/09638237.2021.1922645">four-year project</a> which involved listening to the perspectives of more than 400 people. We wanted to shed light on how common it is for people to feel empty, and why it’s important for researchers and clinicians to start paying attention to this feeling. Our research has allowed us to provide the first ever definition of emptiness based on the descriptions of people who experienced it first hand. This has not only shown the importance of this feeling, but also makes future research possible.</p>
<h2>‘A bottomless jug’</h2>
<p>We spoke to more than 400 people aged 18 to 80 who had reported feeling empty at some point in their lives – some rarely, some all the time. We asked them to complete an online survey where they described what it was like to feel this way.</p>
<p>This resulted in hundreds of emotive, first-hand accounts. Some described feeling empty as being “a kind of bottomless jug that can never be filled” and “a feeling of othering and separation from society” that “sucks all of the life and energy out of you”.</p>
<p>As one participant told us, emptiness is:</p>
<blockquote>
<p>When you feel like everything you do is pointless and you’re just going through the motions. Just trying to fill in the time until you die. Sometimes you have fun or something good happens which can distract you for a while, but ultimately there is a hollowness inside which never goes away. It’s as if you’re transparent and anything positive like love or joy just passes right through you without sticking and afterwards it feels like it was never there at all.</p>
</blockquote>
<p>Others spoke of motivation levels “at complete zero”, and another said:</p>
<blockquote>
<p>It felt as though I wasn’t fully part of the world, I couldn’t feel anything and nothing I did made an impact on events or other people, I ‘existed’ but I wasn’t ‘alive’.</p>
</blockquote>
<p>Interestingly, half of participants had never struggled with a mental health difficulty – showing us that emptiness is not only experienced by people who have received a diagnosis of borderline personality disorder, but that it can be experienced by people with and without mental health problems.</p>
<p>We also identified a strong link between feeling empty often and suicidal thoughts and behaviours, with those who felt empty all of the time more likely to have thought about or attempted suicide. </p>
<p>And, despite never having been given a definition of what was meant by emptiness – and instead asked to speak from their own perspective – hundreds of participants described the same feeling. We found that emptiness was characterised by a sense of inner void, coupled with lack of purpose in life and a sense of disconnection to the people in their lives and the world around them. This left people feeling that they were “going through the motions”, and not able to contribute to the world and their lives as they would like. </p>
<figure class="align-center ">
<img alt="Elderly man sitting at a table, looking tired and depressed." src="https://images.theconversation.com/files/408840/original/file-20210629-20-dbswyg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/408840/original/file-20210629-20-dbswyg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/408840/original/file-20210629-20-dbswyg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/408840/original/file-20210629-20-dbswyg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/408840/original/file-20210629-20-dbswyg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/408840/original/file-20210629-20-dbswyg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/408840/original/file-20210629-20-dbswyg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Having a definition for emptiness will make it easier to help those with this feeling.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/old-age-man-feel-lonely-depressed-253039792">Photographee.eu/ Shutterstock</a></span>
</figcaption>
</figure>
<p>This research has now resulted in the first definition of emptiness based on people’s personal accounts which has been published in a scientific journal. Our hope is that this will make it easier for clinicians to ask people about emptiness, and for researchers to start investigating this feeling which has previously been neglected in our conversations about mental health.</p>
<h2>Widespread feeling</h2>
<p>Our findings lead us to believe emptiness is far more widespread than previously recognised. Feelings of emptiness can be experienced by anyone, regardless of their mental health history – and for some it can be chronic and life threatening. This experience is clearly complex, impacting every aspect of a person’s life and relationships. </p>
<p>Until now, emptiness has received little attention from mental health researchers. But our research has now given a new definition to this feeling, and has highlighted the seriousness of this experience for the people who are effected. Our research also suggests that it might be time to change the way we think about mental health, distress and the support offered – as many people struggle with emptiness, regardless of whether they’ve been diagnosed with a mental health condition or not.</p>
<p>But there’s still lots we don’t know. For example, why do people feel empty – and why do some feel more empty than others? What can we do about it? Answering these questions is likely to have a big impact for many people. By understanding what emptiness is, how it develops, and how to support people who feel this way, lives may be made more meaningful and deaths by suicide prevented.</p>
<p>The next step of this research will involve developing a way of accurately measuring peoples’ experiences of emptiness, which help us in studying it, and may ultimately help reduce the suffering caused by this complex feeling. </p>
<p><em>If you’ve been affected by anything in this article there are free helplines available to support you:</em></p>
<p><em>In the UK, Samaritans can be contacted on 116 123 or email jo@samaritans.org. You can contact the mental health charity Mind by calling 0300 123 3393 or visiting <a href="https://www.mind.org.uk/">mind.org.uk</a></em></p>
<p><em>In other countries – visit IASP or Suicide.org to find a helpline in your country.</em></p><img src="https://counter.theconversation.com/content/163035/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fabio Sani previously received funding from the Economic & Social Research Council (ESRC) for a number of projects broadly concerning social identity, group processes, and health. He is currently receiving funding from the Scottish Government for a project on the psychosocial determinants of non-fatal overdose among people who use drugs. </span></em></p><p class="fine-print"><em><span>Shona Joyce Herron does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Newly published research provides the first ever definition of what it means to feel ‘empty’ — a common struggle rarely recognised by health professionals.Shona Joyce Herron, Trainee Clinical Psychologist, UCLFabio Sani, Professor of Psychology, University of DundeeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1555162021-03-16T18:16:18Z2021-03-16T18:16:18ZCan narcissistic managers fake that they care?<figure><img src="https://images.theconversation.com/files/389435/original/file-20210314-21-mvvna2.jpg?ixlib=rb-1.1.0&rect=0%2C35%2C2000%2C1290&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For narcissistic managers, it's all about them, not their employees. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/selfsatisfied-proud-caucasian-young-man-looks-755500357">Anna Koldunova/Shutterstock </a></span></figcaption></figure><p>Relationships at work matter greatly to our well-being, and perhaps no work relationship affects us more strongly than the one we have with our manager. In fact, people who leave their job frequently report that their manager is their <a href="https://www.gallup.com/workplace/237059/employee-burnout-part-main-causes.aspx">most important reason for doing so</a>.</p>
<p>Managers’ narcissistic tendencies are often a key issue that troubles their relationship with their <a href="https://theconversation.com/toxic-leaders-affect-companies-and-governments-how-to-deal-with-them-78265">employees</a>. Although narcissists tend to make a good first impression, their true nature unfolds over time and <a href="https://doi.org/10.1177/0956797613491970">reveals</a> that they care above all about themselves, not about others.</p>
<p>Our recent <a href="https://doi.org/10.1111/joop.12337">studies</a> show that narcissistic managers are poorly equipped to develop good, sustainable relationships with others because their selfish behaviour and disregard for others erodes what is the basis of all good relationships – trust.</p>
<p>My fellow researchers and I therefore wondered: Could some narcissistic managers develop the ability to camouflage their lack of concern for others and make others trust them by creating the impression that they care?</p>
<h2>How do narcissistic managers erode others’ trust in them?</h2>
<p>Narcissistic individuals display a <a href="https://doi.org/10.1016/j.leaqua.2006.10.005">range of self-centered characteristics</a>, including selfishness, entitlement, arrogance and the exploition of people for personal gain. They consider themselves as more important, talented, and attractive than others, but they are also insecure about themselves and have a strong need to be admired. Narcissists thus simultaneously crave other people’s reaffirmation and validation of their inflated self-image, and feel entitled to attention and admiration.</p>
<p>This duality of craving and feeling entitled to admiration leads narcissistic individuals to consider themselves born to be leaders and to feel entitled to leadership positions, positions in which they may be <a href="https://doi.org/10.1177/1745691619873350">seen and admired</a>. Unfortunately, we tend to interpret a narcissistic individual’s overconfidence as a signal that they are, in fact, competent and that they would make a <a href="https://theconversation.com/narcissistic-leaders-even-children-fall-for-their-superficial-charms-154113">good leader</a>. So narcissists’ aspiration for leadership positions combined with the good first impressions that they make can cause them to rise in hierarchies, which results in narcissistic traits being <a href="https://doi.org/10.1111/peps.12072">relatively common among managers</a>.</p>
<p>Although narcissistic individuals may make a good impression initially, they can be ill-suited to leadership positions, because effective leadership requires developing collaborative, reciprocal, trusting relationships with others. Instead, as our research consistently finds, narcissistic managers are considered less trustworthy by those who work for them. This is because developing trust requires integrity and caring about others, neither of which come natural to narcissistic individuals. </p>
<p>In fact, narcissistic managers are likely to put their own interests ahead of those of others and may even step on others when doing so is needed to achieve personal gain. Consequently, as our studies confirmed, a narcissistic, untrustworthy manager will make people feel unsafe to take risks, make mistakes, and express themselves openly.</p>
<h2>Is it easy to spot a narcissist?</h2>
<p>Because the effects of narcissistic leaders are likely to come out and their true nature may be revealed over time, it is tempting to think that we could easily detect a narcissistic manager. If this is the case, we may simply – through selection tests in organizational recruitments, for example – try to detect them and ensure that they’re not selected for leadership positions.</p>
<p>Such efforts certainly hold merit, as narcissistic individuals are typically not shy about admitting that they want to be admired or even that they overlook the interests of others. Indeed, in general, narcissists <a href="https://doi.org/10.1111/1467-6494.00041">do not present themselves as agreeable or modest</a>. However, narcissists are not incompetent and they have the <em>capability</em> to learn that they may be even more effective in attaining their selfish goals if they present themselves in a socially acceptable way or, in other words, if they camouflage their lack of care and fly under the radar.</p>
<p>A consistent finding in our studies is that some narcissistic managers engage in techniques to manage the impression that others have of them – they actively seek to behave in ways that makes them <em>appear</em> sincere to others. Moreover, our findings indicate that these impression-management techniques can be successful: employees perceive highly narcissistic managers that try to make themselves appear sincere as more trustworthy than their highly narcissistic counterparts who do not engage in this impression management behaviour and, because of this, their employees feel safer to express themselves openly. In a nutshell, they can fake that they care and be successful in doing so.</p>
<h2>What might this fake caring look like?</h2>
<p>When someone behaves in a way that seems caring, it can be difficult to tell whether or not they are faking it. Fortunately, there may be some signs. In general, the fact that narcissistic individuals need to learn how to give others the impression that they care, means that they cannot rely on spontaneous behaviour and responses. This means that their seemingly sincere behaviour is likely to appear awkward or scripted. For example:</p>
<ul>
<li><p>Someone who is truly caring is likely to spontaneously ask you how you are doing, and is likely to be aware of what is going on in your life. In contrast, a person who does not really care is less likely to ask you spontaneously. Instead, it could be that they only ever ask how you are after you have just asked them. It could simply be that your question reminded them to express caring about you in return. Moreover, they may be unlikely to ask follow-up questions after having shown their superficially caring behaviour. After all, they are not truly interested in you.</p></li>
<li><p>Someone who is truly caring is likely to listen and be more empathic. In contrast, if you find yourself telling a story about your own experience and the experience suddenly appears to be about them, their seemingly empathic response to your story might be only an opportunity for them to tell a story about themselves. Similarly, it is possible that their reaction to your story is not empathic at all, remains superficial, and only sticks to the facts.</p></li>
<li><p>At the same time, however, if they only let you talk and never share or relate to what you are saying, it may well be that they have made you believe that they are interested in you but that they do not actually care. Someone who is caring and trustworthy is likely to express trust in you as well – for example, by sharing about their own life – because trustworthy people are likely to see relationships as a two-way street.</p></li>
</ul>
<p>Most people have a natural inclination to trust others who show signs of caring, so we are vulnerable to the assumption that narcissists have good intentions, especially those narcissists who engage in extra effort to appear sincere. Some awareness of this effect and the ways in which we might recognize fake caring is helpful to protect well-intentioned people from being exploited and manipulated.</p><img src="https://counter.theconversation.com/content/155516/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melvyn R.W. Hamstra ne travaille pas, ne conseille pas, ne possède pas de parts, ne reçoit pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'a déclaré aucune autre affiliation que son organisme de recherche.</span></em></p>Narcissism is relatively common among managers and can damage their relationships with employees. Yet some narcissists can enourage trust despite their shortcomings. So how can they be detected?Melvyn R.W. Hamstra, Assistant Professor in Leadership and Organizational Behavior, IÉSEG School of ManagementLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1155492019-05-02T20:13:59Z2019-05-02T20:13:59ZWe need to treat borderline personality disorder for what it really is – a response to trauma<figure><img src="https://images.theconversation.com/files/272170/original/file-20190502-103075-1wodsq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">BPD is common, affecting 1-4% of Australians. </span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/vCfxXxbQRX8">Pablo Varela</a></span></figcaption></figure><p>Borderline personality disorder (BPD) is a highly stigmatised and misunderstood condition. Australians with BPD face considerable barriers to accessing high-quality and affordable care, according to <a href="http://dx.doi.org/10.1111/ap.12400">new research</a> published today.</p>
<p>For every 100 patients we treat in inpatient psychiatric wards, <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jpm.12226">43 will have</a> BPD. People with this condition are <a href="https://www.ncbi.nlm.nih.gov/pubmed/24725357">vulnerable</a>, impulsive, and highly susceptible to criticism – yet they continue to face <a href="http://eprints.hud.ac.uk/id/eprint/26848/">stigma and discrimination</a> when seeking care. </p>
<p>We have come a long way since the days of viewing mental illness as a sign of weakness, but we are lagging behind in our attitude towards BPD. At least part of this stems from the way we frame the condition, and from the name itself.</p>
<p>Rather than as a personality disorder, BPD is better thought of as a complex response to trauma. It’s time we changed its name.</p>
<h2>How common is BPD?</h2>
<p>BPD is strikingly common, <a href="https://www.sane.org/mental-health-and-illness/facts-and-guides/borderline-personality-disorder">affecting between 1% and 4%</a> of Australians. It is <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)16770-6/fulltext">characterised by</a> emotional dysregulation, an unstable sense of self, difficulty forming relationships, and repeated self-harming behaviours. </p>
<p>Most people who suffer from BPD have a <a href="https://www.sciencedirect.com/science/article/pii/S0165178105000508">history of major trauma</a>, often sustained in childhood. This includes <a href="https://www.ncbi.nlm.nih.gov/pubmed/2929750">sexual and physical abuse</a>, extreme neglect, and separation from parents and loved ones. </p>
<p>This link with trauma – particularly physical and sexual abuse – has been <a href="https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.160.11.2018">studied extensively</a> and has been shown to be near-ubiquitous in patients with BPD. </p>
<p>People with BPD who have a history of serious abuse <a href="https://www.sciencedirect.com/science/article/pii/S0165178117312921?via%3Dihub">have poorer outcomes</a> than the few who don’t, and are more likely to self-harm and attempt suicide. Around <a href="https://www.ncbi.nlm.nih.gov/pubmed/15237043">75% of BPD patients attempt suicide</a> at some point in their life. One in ten eventually take their own life.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/borderline-personality-disorder-is-a-hurtful-label-for-real-suffering-time-we-changed-it-41760">Borderline personality disorder is a hurtful label for real suffering – time we changed it</a>
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<p>The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) does not mention trauma as a diagnostic factor in BPD, despite the inextricable link between BPD and trauma. This adds to viewing BPD as what its name suggests it is – a personality disorder.</p>
<p>Instead, BPD is better thought of as a trauma-spectrum disorder – similar to chronic or complex PTSD. </p>
<p>The <a href="https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.160.11.2018">similarities</a> between complex PTSD and BPD are numerous. Patients with both conditions have difficulty regulating their emotions; they experience persistent feelings of emptiness, shame, and guilt; and they have a significantly elevated risk of suicide.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/272168/original/file-20190502-103078-35jh2c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272168/original/file-20190502-103078-35jh2c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272168/original/file-20190502-103078-35jh2c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272168/original/file-20190502-103078-35jh2c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272168/original/file-20190502-103078-35jh2c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272168/original/file-20190502-103078-35jh2c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272168/original/file-20190502-103078-35jh2c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People with BPD are highly susceptible to criticism.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/uggEzuTP7Xk">Andrew Le</a></span>
</figcaption>
</figure>
<h2>Why the label is such a problem</h2>
<p>Labelling people with BPD as having a personality disorder can exacerbate their poor self-esteem. “Personality disorder” translates in many people’s minds as a personality flaw, and this can lead to or exacerbate an ingrained sense of worthlessness and self-loathing.</p>
<p>This means people with BPD may view themselves more negatively, but can also lead other people – including those closest to them – to do the same.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/mood-and-personality-disorders-are-often-misconceived-heres-what-you-need-to-know-94971">Mood and personality disorders are often misconceived: here's what you need to know</a>
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</em>
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<p>Clinicians, too, often <a href="http://eprints.hud.ac.uk/id/eprint/26848/">harbour negative attitudes</a> towards people with BPD, viewing them as manipulative or unwilling to help themselves. Because they can be hard to deal with and may not engage with initial treatment, doctors, nurses and other staff members <a href="https://www.ncbi.nlm.nih.gov/pubmed/24725357">often react</a> with frustration or contempt. </p>
<p>These attitudes are <a href="https://scholarworks.smith.edu/cgi/viewcontent.cgi?article=2041&context=theses">much less frequently seen</a> from clinicians working with people suffering from complex PTSD or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4623286/">other trauma-spectrum disorders</a>. </p>
<h2>What could a name change do?</h2>
<p>Explicitly linking BPD to trauma could alleviate some of the stigma and associated harm that goes with the diagnosis, leading to better treatment engagement, and better outcomes.</p>
<p>When people with BPD sense that people are distancing themselves or treating them with disdain, they may respond by self-harming or refusing treatment. Clinicians may in turn react by further distancing themselves or becoming frustrated, which perpetuates these same negative behaviours. </p>
<p>Eventually, this <a href="https://www.tandfonline.com/doi/full/10.1080/10673220600975121?scroll=top&needAccess=true">may lead to</a> what US psychiatric researcher Ron Aviram and colleagues call a “self-fulfilling prophecy and a cycle of stigmatisation to which both patient and therapist contribute”. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/biology-is-partly-to-blame-for-high-rates-of-mental-illness-in-women-the-rest-is-social-75700">Biology is partly to blame for high rates of mental illness in women – the rest is social</a>
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<p>Thinking about BPD in terms of its underlying cause would help us treat its cause rather than its symptoms and would reinforce the importance of preventing child abuse and neglect in the first place. </p>
<p>If we started thinking about it as a trauma-spectrum condition, patients might start being viewed as victims of past injustice, rather than perpetrators of their own misfortune. </p>
<p>BPD is a difficult condition to treat, and the last thing we need to do is to make it harder for patients and their families.</p><img src="https://counter.theconversation.com/content/115549/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jayashri Kulkarni receives funding from the NHMRC,The Felton Bequest, The Stanley Medical Research Institute (Washington,USA) and for clinical trials work from Jansen Cilag. This article received no direct funding from. any source </span></em></p><p class="fine-print"><em><span>Patrick Walker does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People with borderline personality disorder are often treated as if they have a personality flaw, rather than mental health issues stemming from trauma. It’s time we changed its name.Patrick Walker, Adjunct Research Associate, Monash UniversityJayashri Kulkarni, Professor of Psychiatry, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/949712018-04-16T04:19:19Z2018-04-16T04:19:19ZMood and personality disorders are often misconceived: here’s what you need to know<p>With each new version of the widely-used manual of mental disorders, the number of mental health conditions increases. The latest version (<a href="https://www.psychiatry.org/psychiatrists/practice/dsm">DSM-5</a>) lists around 300 disorders. To complicate things, many share common features, such as depression and anxiety. </p>
<p>The manual is a useful guide for doctors and researchers, but making a diagnosis is not a precise science. So if the “experts” are still debating what’s what when it comes to categorising disorders, it’s not surprising misconceptions abound in the community about certain mental health conditions.</p>
<p>We learn about mental health conditions in a number of ways. Either we know someone who has experienced it, we’ve experienced it ourselves, read about it or seen something on TV. Movies and TV series commonly portray people with mental illness as dangerous, scary and unpredictable. The most popular (mis)representations are of characters with multiple personalities, personality disorders, schizophrenia and bipolar disorder.</p>
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Read more:
<a href="https://theconversation.com/the-emotion-centre-is-the-oldest-part-of-the-human-brain-why-is-mood-so-important-63324">The emotion centre is the oldest part of the human brain: why is mood so important?</a>
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<p>While the media is an important source of information about mental illness, it can misinform the public if reported inaccurately, promoting stigma and perpetuating myths. And <a href="http://www.mindframe-media.info/for-media/reporting-mental-illness/evidence-and-research/evidence-about-mental-illness-in-the-media?a=6322">research shows</a> negative images of mental illness in the media (fictional and non-fictional) results in negative and inaccurate beliefs about mental illness. </p>
<h2>Dissociative identity disorder</h2>
<p>“Multiple personality disorder” or “split personality disorder” are colloquial terms for dissociative identity disorder. Despite being colloquially named a personality disorder, it’s actually a <em>dissociative</em> disorder. </p>
<p>A personality disorder is a long-term way of thinking, feeling and behaving that deviates from the expectations of culture. Whereas in dissociative identity disorder, at least two alternate personalities (alters) routinely take control of the individual’s behaviour. The individual is usually unable to remember what happened when an alter takes over: there are noticeble gaps in their memory, which can be extremely distressing. </p>
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Read more:
<a href="https://theconversation.com/dissociative-identity-disorder-exists-and-is-the-result-of-childhood-trauma-85076">Dissociative identity disorder exists and is the result of childhood trauma</a>
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<p>The popular TV series “The United States of Tara” actually does a pretty good job of portraying dissociative identity disorder. The main character has a series of alters and experiences recurrent gaps in her memory.</p>
<p>While it used to be considered rare, dissociative identity disorder is estimated to affect <a href="https://www.uptodate.com/contents/dissociative-identity-disorder-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis#H1244373">1% of the general population</a>, and is typically related to early trauma (such as childhood abuse). People commonly confuse dissociative identity disorder with schizophrenia. Unlike schizophrenia, the individual is not imagining external voices or experiencing visual hallucinations: one personality literally “checks out” and another appears in their place.</p>
<h2>Borderline personality disorder</h2>
<p>Borderline personality disorder is often misconstrued. People with this condition are often portrayed as manipulative, destructive and violent. In reality, these behaviours are driven by emotional pain: the person has never learned to ask effectively for what they need or want.</p>
<p>It is also often assumed “borderline” means the person <em>almost</em> has a personality disorder. The term “borderline” here creates some confusion. <a href="https://www.ncbi.nlm.nih.gov/books/NBK55415">First introduced in the United States in 1938</a>, the term was used by psychiatrists to describe patients who were thought to be on the “border” between diagnoses (mostly psychosis and neurosis). The term “borderline” has stuck in the diagnosis, but there is now a much better understanding of the causes, symptoms and treatment.</p>
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Read more:
<a href="https://theconversation.com/borderline-personality-disorder-is-a-hurtful-label-for-real-suffering-time-we-changed-it-41760">Borderline personality disorder is a hurtful label for real suffering – time we changed it</a>
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<p>Those with borderline personality disorder have difficulties regulating their emotions. This contributes to angry outbursts, anxiety and depression, and relationships fraught with difficulties. It’s also commonly associated with trauma (such as childhood abuse or neglect). </p>
<p>Many actions of a person with borderline personality disorder (such as self-harm and overdose) are done out of desperation in an attempt to manage difficult and intense emotions. </p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-borderline-personality-disorder-12523">Explainer: what is borderline personality disorder?</a>
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<h2>Bipolar disorder</h2>
<p>While borderline personality disorder and bipolar disorder can look similar (mood problems, impulsive behaviour and suicidal thinking), there are <a href="https://journals.lww.com/co-psychiatry/Citation/2014/01000/Clinical_differentiation_of_bipolar_II_disorder.4.aspx">several key differences</a>. </p>
<p>Bipolar disorder is characterised by extreme mood swings – from severe lows (depression) to periods of high activity, energy and euphoria. The different mood states can seem like a personality change, but a return to the “usual self” occurs once mood stabilises. </p>
<p>While depression is part of borderline personality disorder and bipolar disorder, those with bipolar disorder experience significant “up” mood swings. This is known as mania in bipolar I disorder and hypomania (less intense mania) in bipolar II disorder.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-bipolar-disorder-7502">Explainer: what is bipolar disorder?</a>
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<p>Bipolar mood episodes last longer (four days or longer for “ups” and two weeks or longer for “downs”), with periods of wellness in between, and are less likely to be triggered by external events. And bipolar disorder is more likely to run in families, disrupt sleep patterns, and psychotic symptoms (delusions, hallucinations) can occur during mood episodes.</p>
<p>We all have ups and downs, but bipolar disorder is much more than that with extreme, recurrent mood episodes that are not only distressing, but have a significant long-term impact on key areas of a persons’s life. Positively, with the right treatment, good quality of life is entirely possible despite ongoing symptoms.</p>
<h2>Schizophrenia</h2>
<p>Schizophrenia, meaning “split mind” in Greek, is often confused with dissociative identity disorder. However, the “split” refers not to multiple personalities, but to a “split” from reality. People with schizophrenia may find it difficult to discern whether their perceptions, thoughts, and emotions are based in reality or not. </p>
<p>Hearing voices (auditory hallucinations) is a common symptom, along with seeing, smelling, feeling, or tasting things others can’t. Unusual beliefs (delusions), including some that cannot possibly be true (such as a belief that one has special powers) are also common. So too is disordered thinking, where the person jumps from one topic to another at random, or makes strange associations to things that don’t make sense. They may also exhibit bizarre behaviour including socially inappropriate outbursts or wearing odd clothing that is inappropriate to the circumstances.</p>
<p>Other symptoms of schizophrenia look a lot like depression, such as an inability to experience pleasure, social withdrawal and low motivation. Depressive symptoms are also present in schizophrenia, but are slightly different in that emotion is diminished altogether, rather than a depressed mood per se.</p>
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Read more:
<a href="https://theconversation.com/either-mad-and-bad-or-jekyll-and-hyde-media-portrayals-of-schizophrenia-12391">Either mad and bad or Jekyll and Hyde: media portrayals of schizophrenia</a>
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<h2>Mental health conditions don’t come in neat packages</h2>
<p>Unlike physical conditions, we don’t have a biological test that can magically tell us what mental condition we’re dealing with. Mental health practitioners are carefully trained to observe symptom patterns: the right diagnosis guides the appropriate treatment. </p>
<p>For example, first-line treatment of schizophrenia and bipolar disorder often focuses on medication. While dissociative identity disorder and borderline personality disorders are treated primarily with psychological therapy. </p>
<p>Mental health conditions are serious – whether disorders of personality, mood or somewhere in between. Improved understanding and balanced representation of these conditions is needed to shift stigmas and misconceptions in the community.</p><img src="https://counter.theconversation.com/content/94971/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Media portrayals don’t help misconceptions about disorders such as bipolar, schizophrenia and borderline personality disorder. So what do these terms actually mean?Kathryn Fletcher, Postdoctoral Research Fellow, Swinburne University of TechnologyKristi-Ann Villagonzalo, Postdoctoral Research Fellow, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/757002017-08-08T19:46:40Z2017-08-08T19:46:40ZBiology is partly to blame for high rates of mental illness in women – the rest is social<figure><img src="https://images.theconversation.com/files/176350/original/file-20170630-21076-19boyga.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Gender is a an important determinant of mental health.</span> <span class="attribution"><a class="source" href="https://unsplash.com/search/depression?photo=aLnqDp3B3YU">Naomi August/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p><em>Men and women respond differently to diseases and treatments for biological, social and psychological reasons. In this series on <a href="https://theconversation.com/au/topics/gender-medicine-39178">Gender Medicine</a>, experts explore these differences and the importance of approaching treatment and diagnosis through a gender lens.</em></p>
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<p>Depression and anxiety are known to affect around one in five people, but depression occurs <a href="https://www.researchgate.net/publication/50866070_McLean_CP_Asnaani_A_Litz_BT_Hofmann_SG_Gender_differences_in_anxiety_disorders_prevalence_course_of_illness_comorbidity_and_burden_of_illness_J_Psychiatr_Res_45_1027-1035">twice as often in women</a> as in men. And when it comes to <a href="https://www.beyondblue.org.au/the-facts/depression/types-of-depression">major depressive disorder</a> – the formal diagnosis of the illness – a comprehensive review of almost all population studies conducted to date in Australia, the United States, Puerto Rico, Canada, France, Iceland, Taiwan, Korea, Germany and Hong Kong has reported <a href="http://www.who.int/mental_health/media/en/54.pdf?ua=1">more women than men</a> experienced major depression in their lifetime. </p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-depression-11447">Explainer: what is depression?</a>
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<p>Compared to men, women also have <a href="https://www.ncbi.nlm.nih.gov/pubmed/7492257">significantly higher rates</a> of anxiety and post-traumatic stress disorder (PTSD). While around one in every 12 adults experiences PTSD at some time in their lives, women’s risk of developing PTSD following exposure to trauma is around two times that of men’s. The rate of anxiety disorders has been noted to be four times higher in women compared to men.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/176369/original/file-20170630-8187-132l6v2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/176369/original/file-20170630-8187-132l6v2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/176369/original/file-20170630-8187-132l6v2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=822&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176369/original/file-20170630-8187-132l6v2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=822&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176369/original/file-20170630-8187-132l6v2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=822&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176369/original/file-20170630-8187-132l6v2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1033&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176369/original/file-20170630-8187-132l6v2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1033&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176369/original/file-20170630-8187-132l6v2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1033&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Depression occurs twice as often in women as in men.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/chrisjohnbeckett/34481651433/in/photolist-Ux2tDB-R2NHh2-VDxAtY-SvZXrz-VBvSZA-Vo1vc7-dVy7PS-Upwp21-e3EUtB-QJ4RFK-R4JPis-RBFUaq-s72X9t-dUm8Et-SfDePF-UMq5m6-svbiDe-SVvoRa-jHGKb2-T7MAAV-V3pTk4-UvJhbX-kTEaLx-fw5Xnb-UjHxik-9Wfn1E-T4iQhB-kPdQHB-eehwqb-VJFQ7J-ckvEZQ-TchJpB-mKkCKk-jcovxs-RE9xDX-81zL2t-gvN444-dCrNDH-4vn2Av-S3Vne9-UttxZW-ZPgUf-VwfUBy-f4kEtg-RDKcMt-kPjLxx-T1AboW-V6D2XA-SbFP1Z-qiZx1M">Chris Beckett/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>Men and women still have <a href="http://vuir.vu.edu.au/1656/">different levels of control</a> over the determinants of mental health such as access to resources, status, roles, options and treatments. As such, gender is important in defining susceptibility and exposure to a number of mental health risks. Gender can also explain differences in mental health outcomes. </p>
<p>Although the definition of gender typically refers to social and cultural differences, and is not binary, this article will use the biological definition of being male or female, superimposed by social and cultural aspects, to make its case.</p>
<h2>Psychiatric illnesses</h2>
<p>When it comes to psychiatric illnesses such as schizophrenia and bipolar disorder, the <a href="http://www.who.int/mental_health/media/en/54.pdf?ua=1">overall lifetime prevalence</a> is the same for women as for men. However, gender differences do exist <a href="https://www.ncbi.nlm.nih.gov/pubmed/10074884">within these conditions</a>, in the age of onset, types of symptoms and response to medications. </p>
<p>For instance, men often develop schizophrenia five to eight years earlier than women. Women with schizophrenia have more more hallucinations, and men have more problems with motivation. Men also have more difficulty with memory and concentration compared to women.</p>
<p>Once women develop a serious psychiatric illness like schizophrenia, they are much more likely to <a href="https://link.springer.com/article/10.1023/A:1018719203165">experience sexual and physical abuse</a>, as well as related anxiety, depression and physical ill health. This in turn can exacerbate the underlying mental illness. </p>
<p>The ability to lead a normal life and socialise can affect the long-term adjustment to and outcomes from a severe mental disorder. Daily skills important for a good quality of life, such as shopping, budgeting, cooking and using public transport, vary between men and women globally. </p>
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<img alt="" src="https://images.theconversation.com/files/181000/original/file-20170804-27440-zmrg21.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/181000/original/file-20170804-27440-zmrg21.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/181000/original/file-20170804-27440-zmrg21.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/181000/original/file-20170804-27440-zmrg21.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/181000/original/file-20170804-27440-zmrg21.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/181000/original/file-20170804-27440-zmrg21.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/181000/original/file-20170804-27440-zmrg21.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The ability to perform daily tasks, like using public transport, varies between men and women with mental illness.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/michmutters/9458291780/in/photolist-fpNdCd-hvt25A-3Czw3-7csNN7-di59km-7PU8ZM-di51MD-4p3fFD-a8ifoh-pMtfXw-pxBNG8-6nuHnu-4TyBQ8-7fict3-pgpRnK-4814h-nTJhGE-nhCHTm-jKcDx-4nJghC-5r46ER-4Zf4dL-8QEinp-4SSdwm-jsEwCS-55kp8y-9Mv5YK-5LQvsf-2MLAW-bG5cf6-ipxm-bVEeGU-8YbX9S-VstZYK-9wCXa-8tQnc3-cizYVq-7awuJw-dwj6sw-7DpVoR-pPvkiy-rbRkzo-oqWzjT-8XXwLx-QZrKkm-2tYw8-pLqsxD-6dQrEr-5EEkkw-ePPC3a">Michelle Robinson/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>Men with mental illness <a href="http://journals.sagepub.com/doi/abs/10.1046/j.1440-1614.1999.00538.x">commonly need more help</a> with social skills than unwell women. However, some cultures encourage female independence while others do not. So, the social outcomes are not always clearly male and female differentiated. </p>
<p>Gender <a href="https://www.ncbi.nlm.nih.gov/pubmed/10847318">differences also occur in the course of bipolar disorder</a>. Women are more likely to develop an unpredictable and unstable form of the illness with more related anxiety. They have a greater likelihood of being hospitalised during the manic phase of the disorder. </p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-bipolar-disorder-7502">Explainer: what is bipolar disorder?</a>
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<h2>Suicide rates and seeking help</h2>
<p>Mental health problems are increasingly being recognised in men of all ages, with the highest incidence of mental ill health and suicide reported in elderly men. The <a href="http://www.mindframe-media.info/for-media/reporting-suicide/facts-and-stats">highest suicide rate</a> for Australian males in 2015 (39.3 per 100,000 people) was in men aged 85-plus years, with 68 deaths reported overall in this age group.</p>
<p>This rate was considerably higher than the age-specific suicide rate in all other age groups. The suicide rate for men between the ages of 40 and 55 was around 31 per 100,000 people. For women, suicide rates didn’t differ too much across age groups in 2015 – rates were around 8-10 per 100,000 people. </p>
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Read more:
<a href="https://theconversation.com/elderly-men-have-the-highest-suicide-rate-and-ageism-stops-us-from-doing-something-about-it-46923">Elderly men have the highest suicide rate – and ageism stops us from doing something about it</a>
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<p>One reason women have lower rates of suicide is that they are <a href="http://www.abs.gov.au/ausstats/abs@.nsf/mf/4326.0">more likely than men</a> to seek help. Around 18% of women compared with 11% of men sought help for anxiety in 2007. And 7.1% of women compared with 5.3% of men sought help for mood disorders. Only a <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/mental-pubs-m-mhaust2">small percentage of adolescent boys</a> and men seek help for mental ill health. </p>
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<a href="https://images.theconversation.com/files/181001/original/file-20170804-27446-6ncr9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/181001/original/file-20170804-27446-6ncr9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/181001/original/file-20170804-27446-6ncr9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/181001/original/file-20170804-27446-6ncr9l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/181001/original/file-20170804-27446-6ncr9l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/181001/original/file-20170804-27446-6ncr9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/181001/original/file-20170804-27446-6ncr9l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/181001/original/file-20170804-27446-6ncr9l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The suicide rate is highest among older men.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/neliofilipe/6654019047/in/photolist-b8ZA3k-atn4WU-5DPKMH-VGUAyz-UcysGf-TK3dvq-VBowGd-7RGGxn-WBVciz-DPrL1T-SewAhk-8vVPBJ-7QMshV-7QSq8A-7QQJ3C-qhVJ1Z-5rQcQJ-anum58-rgn9dn-Fj8Ep-rcdxWJ-cRhgXd-qK46Uv-mkktfV-8ZNv6Y-7RH6pK-7j3qwW-WEybeA-dHciUu-7TkZ6G-VH6ACc-SSMkMt-4z9Q9d-S63fb2-W1AwbU-geRzqq-hLdbXS-56JkqV-t6web9-iMX1f6-7QQLfo-7RKYbC-9Dz5De-w9dPiF-7dbj9u-avrPfq-dyVKDa-X9Jkqx-8dU1GZ-UcyDLu">nelio filipe/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>Women are also more likely than men to use services for mental health problems. This may reflect greater female psychological knowledge and acceptance of mental illness. Mental illnesses in men are frequently masked by risky behaviours such as alcohol and drug abuse, anger and aggression, speeding on roads and drink driving. </p>
<h2>Violence against women and hormones</h2>
<p>Women with mental illness <a href="http://www.who.int/mental_health/media/en/242.pdf">often struggle</a> to have their needs recognised by standard psychological and psychiatric treatments. Two areas that clearly impact on women’s mental ill health are often not considered or managed well: violence against women, and the complex interplay between hormone shifts and mental state changes. </p>
<p>Rape, assaults, emotional abuse and deprivation are a spectrum of severely damaging and traumatic events that can have long-lasting adverse effects on women’s mental health. For unclear reasons, the issues of early life traumas in a woman’s life are <a href="http://monash.edu/research/explore/en/publications/do-mental-health-clinicians-elicit-a-history-of-previous-trauma-in-female-psychiatric-inpatients(712918ae-67ab-4c5f-8b75-416123707277).html">often ignored or underplayed</a> in the consideration of mental illness development in later life.</p>
<p>Hormone fluctuations also have a significant impact on mental health across the lifespan of many women. The female hormone oestrogen has several key roles in the brain and provides a protective effect against mental illness. At times of lower oestrogen levels, either pre-menstrual or around the menopause, some women <a href="https://www.ncbi.nlm.nih.gov/pubmed/16585467">experience significant and real depression</a>, as well as anxiety.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-shift-in-social-attitudes-can-make-menopause-a-positive-experience-46742">A shift in social attitudes can make menopause a positive experience</a>
</strong>
</em>
</p>
<hr>
<p>The <a href="http://loraconnor.com/psych280/officeuse/my_lecture_supplies/week01/Depression%20in%20women-Literature%20Review.pdf">incidence of depression</a> increases up to 16-fold in women in their <a href="http://www.mindframe-media.info/for-media/reporting-suicide/facts-and-stats#sthash.pDiX3ZuD.dpuf">mid 40s to early 50s</a> – which is the time of the menopausal process and dropping oestrogen levels.</p>
<p>Disorders caused by hormones, including menopause-related depression but also premenstrual dysphoric disorder (depression in the week prior to menstruation) and postnatal depression, are poorly understood and managed. This disadvantages female sufferers.</p>
<h2>Borderline personality disorder</h2>
<p>Another condition where significant gender disparities exist is borderline personality disorder. This is one of the long-term consequences of violence against women and its understanding and management require a significant rethink.</p>
<p>Borderline personality disorder is a female-dominant diagnosis that <a href="https://www.australiandoctor.com.au/opinions/guest-view/borderline-personality-disorder-is-a-hurtful-label">carries enormous stigma</a>. Men can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3115767/">also be diagnosed</a> with borderline personality disorder, but the presentation of the condition in men is often confounded by the diagnosis of “antisocial personality disorder”. This is a condition where a person experiences a long-term pattern of manipulating, exploiting, or violating the rights of others. This behaviour is often criminal.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/176368/original/file-20170630-13481-1htxzeh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/176368/original/file-20170630-13481-1htxzeh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176368/original/file-20170630-13481-1htxzeh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176368/original/file-20170630-13481-1htxzeh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176368/original/file-20170630-13481-1htxzeh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176368/original/file-20170630-13481-1htxzeh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176368/original/file-20170630-13481-1htxzeh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176368/original/file-20170630-13481-1htxzeh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Borderline personality disorder is a female-dominant diagnosis.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>The hallmark symptoms of borderline personality disorder are deliberate self-harm such as cutting or burning, rage over apparently minor issues, mood swings, poor self-esteem, dissociation (feeling like you’re not in your own body), constant anxiety and difficulties with identity. </p>
<p>Over 80% of people (mainly women) diagnosed with this condition actually <a href="https://www.ncbi.nlm.nih.gov/pubmed/15176757">have early life traumas</a>. These include incestuous sexual, physical abuse and emotional abuse or deprivation. Yet the condition is termed a “personality disorder”, which carries the connotation it is somehow the person’s fault and ignores the common causal agent of trauma in the majority of cases. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/borderline-personality-disorder-is-a-hurtful-label-for-real-suffering-time-we-changed-it-41760">Borderline personality disorder is a hurtful label for real suffering – time we changed it</a>
</strong>
</em>
</p>
<hr>
<p>Biological, psychological and social factors all act together to cause mental illnesses, and these factors are different among men and women. We must acknowledge this and take a more gendered approach to treating men and women with mental ill health, which integrates a number of biological factors with particular behaviours and external events, to provide better outcomes. </p>
<p><em>For help or information call Lifeline on 13 11 14, or MensLine Australia on 1300 78 99 78 or visit beyondblue.org.au.</em></p>
<hr>
<p><strong><em>Read other articles in the series:</em></strong></p>
<p><em><a href="https://theconversation.com/medicines-gender-revolution-how-women-stopped-being-treated-as-small-men-77171">Medicine’s gender revolution: how women stopped being treated as ‘small men’</a></em></p>
<p><em><a href="https://theconversation.com/man-flu-is-real-but-women-get-more-autoimmune-diseases-and-allergies-77248">Man flu is real, but women get more autoimmune diseases and allergies</a></em></p>
<p><em><a href="https://theconversation.com/women-have-heart-attacks-too-but-their-symptoms-are-often-dismissed-as-something-else-76083">Women have heart attacks too, but their symptoms are often dismissed as something else</a></em></p>
<p><em><a href="https://theconversation.com/what-happens-in-the-womb-affects-our-health-as-adults-but-girls-and-boys-respond-differently-76016">What happens in the womb affects our health as adults, but girls and boys respond differently</a></em></p>
<p><em><a href="https://theconversation.com/both-men-and-women-need-strong-bones-but-their-skeletons-grow-differently-across-ages-75915">Both men and women need strong bones, but their skeletons grow differently across ages</a></em></p><img src="https://counter.theconversation.com/content/75700/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jayashri Kulkarni receives funding for research from the National Health and Medical Research Council and various pharmaceutical companies for clinical trial research.No funding was received for this article and there are no conflicts of interest to declare</span></em></p>Gender is important in defining susceptibility and exposure to a number of mental health risks. Gender can also explain differences in mental health outcomes.Jayashri Kulkarni, Professor of Psychiatry, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/472612015-09-09T20:14:13Z2015-09-09T20:14:13ZTackling the stigma: how sports can help change perceptions of mental illness<p>News that Sydney Swans star Lance “Buddy” Franklin, arguably the biggest name in the Australian Football League (AFL), is experiencing a <a href="http://www.sydneyswans.com.au/news/2015-09-08/club-statement-lance-franklin">mental health condition</a> has garnered a lot of media attention. His story highlights not only the persistent stigma surrounding mental illness, but the potential of sport to help tackle it. </p>
<p>Revelations about Franklin’s mental ill-health should come as no surprise, given that <a href="http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/1301.0Chapter11082009%E2%80%9310">almost half the population</a> experiences a mental health issue at some point in their lives, at an <a href="https://www.medibankhealth.com.au/news-article.asp?id=78&t=Expenditure+on+mental+illness+in+Australia+revealed+to+be+%2428.6+billion+per+year&pid=0">estimated cost of A$28 billion a year</a>. Why, then, do we find it so hard to talk about something that’s so prevalent?</p>
<h2>More and more</h2>
<p>Franklin is not the first high-profile athlete to reveal a struggle with mental illness. English cricketer <a href="http://www.telegraph.co.uk/sport/cricket/international/theashes/11697654/Ashes-2015-Jonathan-Trott-achieves-great-closure-by-watching-England.html">Jonathan Trott withdrew from the 2013-14 Ashes campaign</a> citing poor mental health. <a href="http://www.theguardian.com/sport/2015/sep/08/brandon-marshall-interview-athletes-struggle-to-identify-with-mental-illness">American footballer Brandon Marshall from the New York Jets</a> has made it his mission since 2011 to break the taboo associated with mental illness, openly discussing his experience with <a href="http://sports.yahoo.com/blogs/nfl-shutdown-corner/stronger-ever-brandon-marshall-learns-live-borderline-personality-231007042--nfl.html">borderline personality disorder</a>. </p>
<p>Closer to home, AFL player <a href="http://www.heraldsun.com.au/sport/afl/geelong-forward-mitch-clark-in-tears-after-teams-win-over-collingwood/story-fni5f6yf-1227347759122?sv=328087257ba312ba657f3aa5f5495bf9">Mitch Clark’s battle with depression</a> has received national coverage, including his bold appeal to others to reach out.</p>
<p>While these are all positive individual steps, they also highlight the stigma that surrounds mental illness (why raise awareness if something is entirely acceptable to society already?). And they show how our sporting culture and elite sports organisations are uniquely placed to break down this stigma.</p>
<p>The problem is that the <a href="http://thenewdaily.com.au/sport/2015/09/08/buddy-franklins-revelation-moved-goalposts-mental-illness/">culture of sport</a> and, more broadly, notions of Australian masculinity strongly contribute to the stigma surrounding mental illness. They both encourage a “harden up” culture, creating an expectation that people should be able to maintain emotional stability in the face of adversity.</p>
<p>Parallels can be drawn with the “get on with it” approach among first-responders (emergency services). This is the idea that emergency service personnel have a job to do and should ignore the potentially serious psychological impact of their day-to-day work. In an effort to reduce the risk of psychological injury among emergency response crews, organisations such as <a href="http://www.behindtheseenaustralia.com/about-us.html">Behind the Seen</a> are providing workshops to increase awareness of and promote help-seeking behaviour among first-responders.</p>
<h2>Current efforts</h2>
<p>But that’s not to say that sporting organisations aren’t making an effort to positively influence the national discourse on mental illness. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/94237/original/image-20150909-18669-1bl13l6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/94237/original/image-20150909-18669-1bl13l6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/94237/original/image-20150909-18669-1bl13l6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/94237/original/image-20150909-18669-1bl13l6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/94237/original/image-20150909-18669-1bl13l6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/94237/original/image-20150909-18669-1bl13l6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/94237/original/image-20150909-18669-1bl13l6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">American footballer Brandon Marshall from the New York Jets has made it his mission since to break the taboo associated with mental illness.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/c/c0/Miami_Dolphins_wide_receiver_Brandon_Marshall_practices_during_pregame_warm_up_for_the_National_Football_League%27s_2012_Pro_Bowl_game_at_Aloha_Stadium_in_Honolulu_Jan_120129-M-DX861-041.jpg">By Cpl Jody Lee Smith [Public domain], via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>The <a href="https://www.beyondblue.org.au/get-involved/the-beyondblue-national-roadshow/afl-beyondblue-cup-2015">Beyond Blue Cup</a>, now an annual event in the Beyond Blue National Roadshow, is a prime example of the potential for sport to promote awareness and reduce stigma at a national level. This match is played in the major football codes (AFL, <a href="https://www.beyondblue.org.au/media/media-releases/media-releases/-i-beyondblue-i-nrl-bulldogs-and-knights-team-up-to-raise-awareness-of-depression-and-anxiety-in-mackay-in-the-lead-up-to-the-i-beyondblue-i-cup">NRL</a> and <a href="https://www.beyondblue.org.au/docs/default-source/media-release-pdf/mr-280.pdf?sfvrsn=0">A-League</a>) while raising money and awareness for mental health services. </p>
<p>In the United Kingdom, sporting bodies have teamed up with the deputy prime minister and committed to removing the stigma and prejudice around mental health from the “<a href="https://www.gov.uk/government/news/deputy-prime-minister-launches-mental-health-in-sport-initiative">pitch to the playground</a>” (#SportMinds). These organisations have agreed to promote well-being and good mental health policies and to tackle discrimination on the grounds of mental health.</p>
<p>On a smaller scale, a group of surfers from Sydney’s Bondi Beach formed a not-for-profit organisation called <a href="http://onewaveisallittakes.com/">OneWave</a> to tackle stigma through surfing, while wearing fluorescent clothes, to stimulate discussion of mental health among surfers and other beach users. </p>
<h2>A vehicle for change</h2>
<p>Using sport as a vehicle to de-stigmatise social issues is not a new phenomenon. The <a href="http://www.un.org/wcm/content/site/sport/home/sport/sportandmdgs">United Nations Office of Sport for Development and Peace</a> has long advocated sports to promote social inclusion of stigmatised and marginalised groups. But sport programs that target mental illness appear to be an exception. Discussing mental illness continues to be <a href="https://www.newscientist.com/article/dn23729-the-mental-illness-taboo-is-a-problem-for-all-of-us/">taboo</a> across many cultures. </p>
<p>The evidence supporting the role of sport in promoting mental health in marginalised groups, such as <a href="http://jsfd.org/article/exploring-the-impact-of-sport-participation-in-the-homeless-world-cup-on-individuals-with-substance-abuse-or-mental-health-disorders/">homeless people</a> and <a href="http://www.biomedcentral.com/1471-2458/14/619">children affected by war</a>, is only just emerging. So despite growing support for the potential of sport to address stigma in mental illness, more work is clearly needed. </p>
<p>Franklin’s story is an opportunity to de-stigmatise mental illness among one of the “toughest” audiences. By publicly <a href="http://www.abc.net.au/news/2015-09-09/afl-community-supports-lance-franklin-in-mental-health-battle/6760976">embracing one of its stars</a>, the AFL is helping to normalise the experience of mental illness, pushing back against perceptions that it reflects some kind of weakness. </p>
<p>In a country that prides itself on international prowess on the sporting field, de-stigmatising mental illness through the stories of sporting heroes is a powerful way of starting a conversation. Community perceptions can change with greater awareness that no one is too tough or immune.</p><img src="https://counter.theconversation.com/content/47261/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Lance ‘Buddy’ Franklin’s story highlights not only the persistent stigma surrounding mental illness, but the potential of sport to help tackle it.Justin Richards, Post-Doctoral Research Fellow, University of SydneyPhilip Ward, Associate Professor, Psychiatry, UNSW SydneySimon Rosenbaum, Post-doctoral Fellow, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/367802015-03-23T19:16:25Z2015-03-23T19:16:25ZExplainer: what are personality disorders and how are they treated?<figure><img src="https://images.theconversation.com/files/75327/original/image-20150319-1572-fx7wrq.jpg?ixlib=rb-1.1.0&rect=0%2C63%2C640%2C416&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Narcissism is a key trait in the subset of 'dramatic, emotional and erratic' personality disorders.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/shellysblogger/2444973188/in/photolist-4J48m9-5yGWfW-qVPfN-6aFL5J-7mgvzk-4cCMaF-2QCHxC-7JKLt-4yCNvz-dZTe8P-76AeMd-5w9Kz-6htQfp-mdn2z-eCUtvR-7nmbBt-48oiUx-f9FzCh-mdqGU-3VkLs-3VkLv-2GHXN-aokpd-7FiNE6-mdmx7-hjkcyS-4xKw-g9mrA-ogDr6A-apr1FT-pwpkWy-5Ky7GE-6Z4RTF-7D9k8c-6cDxG4-oHcsx3-6mQMA2-amSiMy-8zXrV-pehEzB-4Pp4-HcKT-g9YLw-qvn7Z-7DEe5Q-PLeE-2qkDt-2kcgA-dRpyHF-Qps5">ShellyS/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>Filmmakers know personality disorders make for compelling viewing. Think of attention-seeking Scarlett O'Hara in Gone with the Wind (1939). Or the manipulation and callous disregard for others in Silence of the Lambs (1991), The Talented Mr. Ripley (1999) and Chopper (2000). Then there are the fears of abandonment and emotional instability in Fatal Attraction (1987) and Girl, Interrupted (1999).</p>
<p>Cinema is less adept, however, at showing the ordinary joys, heartache and sometimes suicidal despair of the friends, workers or relatives we might know with personality disorders.</p>
<h2>What makes a personality ‘disordered’?</h2>
<p>Personality describes individual characteristic patterns of thinking, feeling and behaving. A personality disorder is a class of mental disorders that are diagnosed when these patterns are repeatedly and seriously inflexible and dysfunctional, over an extended period of time. </p>
<p>Personality disturbances have long been recognised through history. Narcissism takes its name from the Greek myth of 50BC. Beautiful Narcissus was transfixed by his reflection in a pool of water. The longer he stared, the more he was driven by both passion and heartache. Over time he died in this state of self-absorbed despair.</p>
<p>People with personality disorders behave and perceive themselves, and others, in a markedly different way to most in their culture. These ideas and behaviours tend to develop in adolescence or early adulthood and are enduring. This can cause significant distress and impairment in all facets of life. </p>
<h2>How common are they?</h2>
<p>Personality disorders represent one of the most prevalent and severe mental health conditions. Around <a href="http://link.springer.com/article/10.1007/s001270050276#page-1">6.5% of Australian adults</a> will have a personality disorder over their lifetime. Data samples of more than 21,000 people worldwide, including Europe, the Americas, Africa and Asia, show a similar prevalence of <a href="http://bjp.rcpsych.org/content/195/1/46.long">6.1%</a>. </p>
<p>About <a href="http://ajp.psychiatryonline.org/doi/abs/10.1176/ajp.149.2.213">40% to 60% of psychiatric patients</a> have a personality disorder, with similar rates in drug and alcohol units and prisons. </p>
<p>Personality disorders account for about <a href="https://ihmri.uow.edu.au/content/groups/public/@web/@ihmri/documents/doc/uow177533.pdf">one in four</a> mental health emergency visits and inpatient hospitalisations.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/75053/original/image-20150317-11980-mvse0t.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/75053/original/image-20150317-11980-mvse0t.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/75053/original/image-20150317-11980-mvse0t.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/75053/original/image-20150317-11980-mvse0t.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/75053/original/image-20150317-11980-mvse0t.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=552&fit=crop&dpr=1 754w, https://images.theconversation.com/files/75053/original/image-20150317-11980-mvse0t.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=552&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/75053/original/image-20150317-11980-mvse0t.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=552&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Scarlett in Gone with the Wind is a classic illustration of histrionic personality disorder.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/marysolra/12990592524/in/photolist-34D8Yw-bys4k1-nvZrLd-9cXNF6-7ofDdv-bMmKuR-9d1VsC-9d1SDJ-94WHhV-qCEUjM-nvZWVT-nQgqYp-nvZXpt-nLrjx5-nNqTy3-nvZgcW-nvZXDB-bys4os-kMWbzb-7HSegc-nK6enP-qnpjir-poLNBR-9d1Jso-9cXi1r-9d1y9d-9d1xnS-9d1FyY-9d1Ted-9cXN9D-9cXPui-9cXPPZ-4hPBzv-kMWbBL-nNqUdE-nvZrwA-5z4Avj-nvZgHA-nNbMNk-6ZLKvo-bys4sJ-nNtTwz-kMUNsr-bys4mS-nNjhQ5-nQgqoX-qnnXpX-5z4Jqs-nvZqx1-5yZwq2">Razi Marysol Machay/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>How are they diagnosed?</h2>
<p>Personality disorder is a diagnosed mental illness included in both the World Health Organization’s <a href="http://www.who.int/classifications/icd/en/">International Classification of Diseases</a> (ICD-10, 1994) and the American Psychiatric Association’s <a href="http://www.psychiatry.org/practice/dsm">Diagnostic and Statistical Manual of Mental Disorders</a> (DSM-5, 2013). </p>
<p>Although there is considerable individual variation, four broad areas of difficulty are common:</p>
<ul>
<li>regulating emotions, such as sudden surges of anger or despair</li>
<li>disturbed relationships, such as being aloof or overly familiar</li>
<li>confused thinking: difficulty understanding the self and misperceiving others’ intentions</li>
<li>associated problem behaviours, such as impulsiveness with drug use, promiscuous sexual behaviour, or self-harm. </li>
</ul>
<h2>What are the causes?</h2>
<p>Personality disorders appear to have both genetic and environmental causes. Individual genetic differences in temperament and attachment patterns early in life seem to play a role, as some people appear pre-wired to be more hypersensitive or ambivalent about bonding with others. </p>
<p><a href="http://www.psyn-journal.com/article/S0925-4927%2812%2900040-6/abstract">Imaging studies</a> of brain functioning report reductions in amygdala and hippocampal regions, perhaps reflecting the difficulties in regulating emotions and integrating autobiographical memories. </p>
<p>Compounding these difficulties is environmental trauma, including experiences of neglect or abuse during childhood or young adulthood, often found in the histories of those with severe personality dysfunction. </p>
<h2>What are the sub-types?</h2>
<p>There is little consensus among experts about personality disorder subtypes. DSM-5 lists ten, clustered into three groups: </p>
<ul>
<li>the “odd and eccentric” (paranoid, schizoid, schizotypal)</li>
<li>the “dramatic, emotional and erratic” (antisocial, <a href="https://theconversation.com/explainer-what-is-borderline-personality-disorder-12523">borderline</a>, histrionic, narcissistic)</li>
<li>the “anxious and fearful” (avoidant, dependent and obsessive-compulsive).<br></li>
</ul>
<p>Yet a section at the back of DSM-5 proposes to reduce the subtypes to six: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, schizotypal. This was meant to replace the current ten, but deep divisions in the DSM-5 personality disorder working group (two members resigned) forced the DSM committee to move this proposal into an “emerging measures and models” section. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/75048/original/image-20150317-13671-pssz1r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/75048/original/image-20150317-13671-pssz1r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/75048/original/image-20150317-13671-pssz1r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/75048/original/image-20150317-13671-pssz1r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/75048/original/image-20150317-13671-pssz1r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/75048/original/image-20150317-13671-pssz1r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/75048/original/image-20150317-13671-pssz1r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Personality patterns are difficult to change.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/genista/699082840">Kai Schreiber/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>The ICD-11 system due 2017 will likely replace all subtypes with a single disorder – personality disorder – rated on severity: mild, moderate, severe. </p>
<p>This will help overcome the lack of consensus, as subtypes tend to significantly overlap, and will align the ICD system with <a href="http://health.vic.gov.au/abf/history.htm">activity-based or casemix</a> health funding models. Therefore, a diagnosis of severe personality disorder – whatever subtype – will justify funding longer-term and more intense treatments over those with milder severity. </p>
<p>ICD-11 has not altogether abandoned individual differences, allowing four descriptors, likely to be named dissocial (similar to antisocial), negative affective (similar to borderline), anankastic (similar to obsessive compulsive), and detached (similar to schizoid or schizotypal). </p>
<h2>How are they treated?</h2>
<p>Research over the past 20 years shows that psychological therapies work for many people with personality disorders. The <a href="http://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2009.09010039">two-thirds</a> who remain in treatment for a year achieve significant benefits. </p>
<p>But personality patterns are difficult to change. The median duration of evidence-based therapy for adults is about one year – at least 32 sessions – but many require longer programs. </p>
<p>There is little evidence that medications are an effective treatment. </p>
<p>Recently published <a href="https://www.mja.com.au/journal/2013/198/9/improved-prognosis-borderline-personality-disorder">clinical practice guidelines</a> emphasise the importance of intervening early with adolescents. A diagnosis can be made in young people from about age 13 to 15 if problems persist for more than a year. </p>
<p>New models of care are being implemented, including our own <a href="https://ihmri.uow.edu.au/content/groups/public/@web/@ihmri/documents/doc/uow177533.pdf">step down model</a> to better manage this disorder. This involves offering a brief personality disorders-friendly psychological <a href="https://ihmri.uow.edu.au/content/groups/public/@web/@ihmri/documents/doc/uow188404.pdf">intervention</a> within one to three days of crisis, followed by assessment and care planning for <a href="https://ihmri.uow.edu.au/content/groups/public/@web/@ihmri/documents/doc/uow189005.pdf">appropriate</a> longer-term support. </p>
<p>This model is based on the findings from recent randomised controlled trials that weekly <a href="http://www.sciencedirect.com/science/article/pii/S0140673614613945">generalist psychological therapies</a> can be as effective as more intensive specialist programs, and are easier to learn and implement.</p>
<p>Psychotherapy can be hard for those involved, especially during the early months, as developing a secure trusting relationship with a psychologist is difficult because of the nature of the disorder. </p>
<p><a href="http://guilfordjournals.com/doi/abs/10.1521/pedi_2013_27_108">Research</a> from our team has demonstrated how ordinary therapists go into consultations with borderline and depressed patients with the same desire to help, but with the former they leave the consultation room more depleted and distressed – even if they are very trained and experienced. </p>
<p>Similarly, family, relatives and carers of people with the disorder <a href="http://guilfordjournals.com/doi/abs/10.1521/pedi_2014_28_136">also report</a> significant emotional burden in their caring role. </p>
<p>Maintaining compassion, hopefulness and patience despite setbacks is important, and better treatments and the experiences of people who have recovered, are now challenging the stigma surrounding personality disorder.</p><img src="https://counter.theconversation.com/content/36780/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brin F.S. Grenyer receives funding from NSW Health to direct the Project Air Strategy for Personality Disorders.</span></em></p>Personality disorders have been richly illustrated by filmmakers. Think of attention-seeking Scarlett in Gone with the Wind. Or the villains in Silence of the Lambs and The Talented Mr. Ripley.Brin F.S. Grenyer, Professor of Psychology, University of WollongongLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/125232013-07-05T04:28:42Z2013-07-05T04:28:42ZExplainer: what is borderline personality disorder?<figure><img src="https://images.theconversation.com/files/26537/original/9rx4crn8-1372644928.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Borderline personality disorder is characterised by problems regulating emotions and thoughts.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p>We all possess a unique set of personality traits that make us who we are. These are the usual ways we perceive, think, feel, behave and relate to others, and they tend to be consistent across time and situations. </p>
<p>Personality traits can become “disordered” when they’re extreme and/or inflexible, making it difficult for the person to adjust to their environment. This causes significant distress and disruption to the lives of those with the disorder. And because it’s difficult to form and maintain relationships, it also affects the lives of those around them. </p>
<p>Borderline personality disorder (BPD) is a severe mental disorder characterised by problems regulating emotions and thoughts, unstable interpersonal relationships and self-image, and impulsive and self-damaging behaviour. The disorder exists along a continuum of severity, with symptoms varying from person to person. These might include: </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/26538/original/d3pytp9k-1372645213.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/26538/original/d3pytp9k-1372645213.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/26538/original/d3pytp9k-1372645213.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/26538/original/d3pytp9k-1372645213.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/26538/original/d3pytp9k-1372645213.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/26538/original/d3pytp9k-1372645213.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/26538/original/d3pytp9k-1372645213.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Around 3% of the population – and one fifth of psychiatric patients – have BPD.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
</figcaption>
</figure>
<ul>
<li>emotional volatility</li>
<li>excessive anger</li>
<li>“black and white thinking” about relationships (being either all good or all bad)</li>
<li>a distorted, unstable or unformed sense of self</li>
<li>intense fears of abandonment</li>
<li>chronic feelings of emptiness</li>
<li>recurrent, deliberate self-harm (such as cutting) </li>
<li>impulsive behaviours with a high likelihood they will cause damage, such as impulsive alcohol use, repeated unsafe sex, binge eating and so on</li>
<li>feelings of unreality and suspicion when under stress. </li>
</ul>
<p>BPD was officially recognised by the psychiatric community in 1980 and is currently diagnosed when a patient has at least five of the nine criteria listed in the American Psychiatric Association’s <a href="http://www.dsm5.org/Pages/Default.aspx">Diagnostic and Statistical Manual of Mental Disorders</a> (DSM-5). While experts generally agree that “borderline personality disorder” is a misnomer, based on the now disbelieved theory that BPD lies on the “border” between “neurosis” and “psychosis”, they have been unable to reach a consensus on a more accurate term.</p>
<p>The disorder affects 1% to 3% of youth and adults and one-fifth of psychiatric patients, usually beginning in adolescence or early adulthood. This, of course, increases the potential for further developmental disruption into adulthood. </p>
<p>People with BPD also have high rates of psychiatric disorders, such as depression, anxiety, and eating disorders and alcohol and other drug use. Sadly, up to <a href="http://www.ncbi.nlm.nih.gov/pubmed/22113831">10% of adults with the disorder</a> commit suicide. </p>
<h2>Causes and risk factors</h2>
<p>Our understanding of developmental pathways leading to BPD has been improved by recent research studies, but there is still much that is unknown. However, we <em>know</em> that people with a personality disorder don’t choose to feel the way they do. </p>
<p>It’s likely that genetics and environment play a role, with genetically “sensitive” individuals at <a href="http://www.ncbi.nlm.nih.gov/pubmed/22009682">greater risk</a> of BPD if they find themselves in an enabling environment. A number of childhood and parental demographic characteristics, bad childhood experiences, early relational difficulties, and unhelpful parenting styles are risk factors for BPD. </p>
<p>But these risk factors are common to many psychiatric disorders, <a href="http://www.ncbi.nlm.nih.gov/pubmed/22009682">making it hard to explain</a> why an individual might develop BPD, rather than another disorder.</p>
<p>Preliminary studies also suggest the brain regions involved in the regulation of emotions and behaviour play an important role in BPD. </p>
<h2>Treatment</h2>
<p>The treatment of BPD has progressed significantly over the past two decades, with new <a href="http://www.nhmrc.gov.au/guidelines/publications/mh25">Australian guidelines</a> outlining interventions for the management of BPD in youth and adults at all levels of the health-care system.</p>
<p>Several <a href="interventions%20at%20all%20levels%20of%20the%20health-care">structured psychological therapies</a> have been specifically designed for BPD. The best known and most widely practised of these is <a href="http://psychcentral.com/lib/2007/an-overview-of-dialectical-behavior-therapy/all/1/">Dialectical Behaviour Therapy</a> (DBT). This combines individual and group therapy and is directed at teaching skills to regulate intense emotional states and to reduce self-destructive behaviours. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/26379/original/7vttkyq3-1372387583.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/26379/original/7vttkyq3-1372387583.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=356&fit=crop&dpr=1 600w, https://images.theconversation.com/files/26379/original/7vttkyq3-1372387583.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=356&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/26379/original/7vttkyq3-1372387583.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=356&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/26379/original/7vttkyq3-1372387583.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=448&fit=crop&dpr=1 754w, https://images.theconversation.com/files/26379/original/7vttkyq3-1372387583.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=448&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/26379/original/7vttkyq3-1372387583.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=448&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">BPD has a reputation as being difficult to treat.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Some features common to all of the effective therapies include having a clear treatment framework, managing emotions during therapy, the therapist being active with the patient, and using exploratory and change-oriented interventions.</p>
<p>When these are conducted by trained and supervised health professionals, they are effective in improving the lives of those with BPD by reducing self-destructive behaviours and improving emotional control, interpersonal relationships and vocational functioning.</p>
<p><a href="interventions%20at%20all%20levels%20of%20the%20health-care">Research shows</a> that medications should not be the main treatment for BPD. Medications can be used for co-occurring problems (such as depression) and might have a very limited role as a specialist treatment for some of the symptoms of BPD, and they can lead to long-term complications.</p>
<h2>Treatment hurdles</h2>
<p>Many people with BPD have experienced significant adversity in their early lives, which is likely to be both a cause and an effect of BPD – and it often continues into adult life. This requires particular sensitivity among health-care professionals. </p>
<p>But BPD has an undeserved reputation among clinicians of being difficult to treat. Complications arise in part because the interpersonal problems at the heart of BPD also affect relationships with professionals. Consequently, patients can encounter prejudice and discrimination within the health-care system and this often compounds their difficulties.</p>
<p>While BPD is a severe psychiatric disorder, it responds well to treatment. The principal challenge is to strengthen the health-care system so that it can provide timely, high-quality, consistent, respectful and collaborative care for people with BPD.</p><img src="https://counter.theconversation.com/content/12523/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Chanen receives funding from the National Health and Medical Research Council, the Australian Research Council, New South Wales Department of Health. The Orygen Youth Health Research Centre receives unrestricted philanthropic funding from the Colonial Foundation.</span></em></p>We all possess a unique set of personality traits that make us who we are. These are the usual ways we perceive, think, feel, behave and relate to others, and they tend to be consistent across time and…Andrew Chanen, Director of Clinical Services, Orygen Youth Health, Associate Professor, the Centre for Youth Mental Health, The University of Melbourne, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.