The Illusion of Bipolar Disorder Among Men: When is it Something More?
Thanks to various social media platforms and high-profile celebrities speaking out about their mental health, many of us have heard of Bipolar Disorder in one way or another. For those of you that have not done so already, I encourage you to read my previous blog, (Riding the Emotional Roller Coaster: Is it Bipolar Disorder?) for an overview of what Bipolar Disorder is (and what it is not).
As a follow-up, I wanted to refine this topic further and look at Bipolar Disorder in men, specifically. In my experience, men are commonly diagnosed with Bipolar Disorder based upon their initial complaint of “mood swings” only to find out there is a more widespread, maladaptive way of relating to the world indicative of a personality disorder.
In general, a personality disorder is a longstanding and pervasive pattern of both internal experiences and behaviors that deviate from the person’s cultural norms with regard to how they perceive themselves, other people, and events; how they experience and express their emotions; how they function within social relationships; and their impulse control.
Among the 10 personality disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Borderline Personality Disorder is one that is marked by a consistent pattern of instability and when individuals present upon intake with inconsistent mood, it is easy to see how clinicians can be fooled into diagnosing Bipolar Disorder if they aren’t proficient in assessing such symptoms further.
What is Borderline Personality Disorder?
Without going too far into a history lesson on the origin of this disorder and how it has progressed through the years, the term Borderline Personality was first proposed in the United States in 1938 to describe a group of patients that were neither psychotic nor neurotic, which were traditionally the only two camps of psychiatric disorders (compared to present day where we have over 200 classified forms of mental illness).
These patients bordered between these two groups with an overarching pattern of instability. Such individuals were noted to fluctuate in their self-image, going between periods of confidence to utter self-despair, as well as experiencing rapid changes in mood with marked fears of abandonment and rejection. They were also observed to have a strong tendency towards suicidal thinking and self-harming behaviors.
Fast forward several decades and while research has helped improve our understanding of Borderline Personality Disorder (BPD), it remains hallmarked by a pattern of instability in a number of areas, including mood, relationships, and self-image. BPD is one of the more common personality disorders, with estimates it affects at least 2% of adults in the United States.
So how does one develop BPD?
While there are several different theories established within the field, research continually relates the disorder back to early childhood attachments and certain adverse childhood events. Infants commonly form their first attachment with their mother but this primary attachment can occur with their father or other individuals who provide comfort, nurturance, and express an interest in the infant on a regular basis. Such nurturance and comfort are key to forming an attachment, providing a “home base” where the child feels safe to explore knowing there is a stable caregiver they retreat back to if they feel scared or overwhelmed.
Experiences of abandonment, abuse, and rejection can prevent attachments from being formed or disrupt those that have already been established given how diametrically opposed they are to feelings of safety, stability, and nurturance. A similar effect can be seen for caregivers who are ambivalent; at times being protective and nurturing towards the child while abandoning and rejecting them at others. Such dynamics in early childhood set the stage for BPD, with a more detailed account of how the disorder shows up in men provided below.
Gender Differences Among those Diagnosed with BPD:
Gender can have a notable impact on the presentation of certain psychiatric conditions, which can be traced back to several behavioral differences commonly seen between boys and girls when they are younger, with boys typically viewed as more active and rough while girls are observed to be more focused on inward, imaginative, and relationship-based play.
Despite these outer, behavioral differences between boys and girls, they do not equate to inner, personality-based differences and have contributed to gender stereotypes that boys are tough while girls are sensitive. Such stereotypes continue into adulthood where men are thought of as rugged and resilient while women are viewed as inherently delicate and sensitive.
These stereotypes permeate so many aspects of our culture and infiltrate our expectations of people based on gender, both consciously and unconsciously. It is no surprise, then, to find out that traditional gender norms can affect the way psychiatric disorders present, with clinicians not impervious to their own gender biases when assessing and diagnosing their clients. Given men are believed to be less emotional, when they do come into treatment reporting mood fluctuations, it is not uncommon to first attribute their complaints to a more biologically based illness, such as Bipolar Disorder. After all, being emotional can’t be part of the personality of a man!
While it was believed that women were diagnosed with BPD three times the rate of men, such prevalence rates were captured strictly within treatment centers, with females traditionally outnumbering men in such settings, skewing results. When research broadened their sample, results suggest men and women have similar prevalence rates. The settings in which men and women with BPD are found are largely influenced by the way the disorder shows up based on gender.
On the surface, men with BPD are commonly observed to have substance use problems, anger management difficulties, and risk-taking behaviors that ignore the welfare of themselves and others. As such, they are commonly found in substance abuse or correctional facilities. Women, on the other hand, often present with more obvious symptoms of disordered eating, identity concerns, and post-traumatic stress disorder, contributing to their higher numbers within traditional mental health facilities.
How do Bipolar Disorder and BPD Look Similar in Men? How Are They Different?
A recent report in the Journal of Clinical Psychiatry found that 40% of individuals with BPD had been misdiagnosed with Bipolar Disorder. Why such a high number? Both conditions are marked by impulsivity, instability in mood, irritability/anger, depression, disrupted social relationships, and suicidality. Further, symptoms of BPD may not present early on in males as they may come across quite stable in the more outer layers of their life, such as work and upon intakes for treatment.
However, the deeper and more emotionally charged their relationships become, the more likely their BPD pathology comes to life. Such difficulties are commonly seen within their romantic relationships and close friendships, as well as with their children at times. As previously noted, BPD often co-occurs with other mental health conditions, such as anxiety and depression that tend to be at the forefront of the clinical picture, causing mental health professionals to miss the bigger picture and context of which such symptoms are occurring within.
One of the hallmark differences between Bipolar Disorder and BPD is how long the various mood states last, as the male with BPD may cycle through mood states (depression, anger, contentment) within the span of a few hours or days while bipolar mood states last longer. It is also more likely that the mood fluctuations in BPD are triggered by external events/stressors while those occurring within Bipolar Disorder can appear more biologically based and unpredictable.
Then there are the psychological conflicts that underlie the mood states within BPD that help delineate it from Bipolar Disorder. If we refer back to the disrupted attachments with caregivers in early childhood as a primary source of BPD, Dr. Nowinski details a subsequent feeling of insecurity in his book, Hard to Love: Understanding and Overcoming Male Borderline Personality Disorder. Dr. Nowinski defines such insecurity as a lingering feeling you cannot count on your loved ones, that somehow you will be let down, rejected, or abandoned by them.
While this insecurity has its root in actual experiences from earlier in life, it is not necessarily representative of current relationships. Interpersonal conflicts arise when this emotional baggage gets erroneously applied to present-day relationships that by and large are healthy and stable.
Men with BPD may also be observed with what Dr. Nowinski refers to as “free-floating anxiety”, or a vague but persistent fear that hovers over someone. While the male may label it as anxiety, they may have a difficult time elaborating on what they are anxious about. This is because the source of their anxiety has little to do with current stressors but stems from long-standing insecurity and distrust created in their early attachments.
Men often cope with this anxiety by overeating, abusing alcohol, smoking marijuana, using other drugs (particularly downers), working excessive hours, over-exercising, and engaging in compulsive sex. In relation to unstable self-image, men with BPD often experience periods of self-hatred that stem from a common assumption by a child that if they are abused, rejected, or abandoned, it is their fault; they must be inherently bad, inferior, or unlovable.
Such insecurity and self-hatred result in jealousy and possessiveness within relationships, particularly romantic ones. Sex can oftentimes be confused with intimacy because it becomes the way in which the man with BPD feels reassured he is still loved and provides a short-term fix for their anxiety.
Lastly, relationships for men with BPD can be negatively impacted by poor boundaries. A relationship entails two separate people coming together to form an “us” and while many aspects of their lives begin to overlap as the relationship progresses, it is healthy for each person to maintain a certain level of individuality within the relationship, or separateness from the other. For men with BPD, large areas of individuality are experienced as threatening given they evoke feelings of insecurity and anxiety. As such, there is a tendency for their closest relationships (particularly romantic ones) to be intense and highly interconnected or inseparable.
As you can see, symptoms of Bipolar Disorder and male BPD can overlap, particularly upon the first look and when focusing on a more surface-level complaint of mood irregularities. With true Bipolar Disorder, mood episodes are as far as it goes; however, with male BPD, changes in mood are just the tip of the iceberg with longstanding conflicts in self-image and relationships hiding beneath the surface.
Given traditional gender roles within our society that hold women to be more emotionally unstable as part of their inherent personalities, borderline personality pathology has often been overlooked in men and misdiagnosed as Bipolar Disorder. In order for the proper treatment plan to be developed, it is important to meet with a qualified clinician who is able to assess whether such mood symptoms are part of a larger clinical picture and provide the most accurate diagnosis. Otherwise, treatment may be putting a bandaid on a wound that has an underlying infection. Without treating the infection, the injury is just going to keep coming back and getting worse.
If you’re struggling with mood instability and would like to have more clarity about how to manage your mood or if you have questions about whether you could be struggling with Bipolar Disorder or Borderline Personality Disorder, contact us to schedule a session with Dr. Taylor Phillips.
Dr. Taylor is a Licensed Psychologist located at our beautiful Coral Springs office who also provides online counseling across the state of Florida. Give us a call today at 954-391-5305 to schedule your complimentary consultation to see how Dr. Taylor can help you live your best life!
***Disclaimer, this article should not be used to diagnose yourself or someone else. If you have questions or concerns you or someone you love may be experiencing Bipolar Disorder or Borderline Personality Disorder, it is important you meet with a qualified expert.