She Must Be Crazy: Psychiatric Discourse, The “Personality Disorders”, and the Social Regulation of Subversive Women
Psychiatric Discourse, The “Personality Disorders”, and the Social Regulation of Deviant Women
“I have gone out, a possessed witch, haunting the black air, braver at night;
dreaming evil, I have done my hitch over the plain houses, light by light:
lonely thing, twelve-fingered, out of mind.
A woman like that is not a woman, quite.
I have been her kind.” (Sexton 1960a)
Deviant females have been labeled and subjected to coercive methods of “correction” throughout history. The violation of prescribed social roles and the transgression of standards regarding culturally “acceptable” behaviour for a woman guarantees subjection to the regulatory mechanisms of society’s most powerful institutions. Using sociological theory, genealogy, and critical discourse analysis, this paper will examine the pervasive power of psychiatry and the larger psy-establishment in current Western culture, by tracing its remarkable success in regulating women, suppressing the possibility of female organization and revolutionary action, and perpetuating the same restrictions on a woman’s experience of the world that have been imposed throughout recorded history.
Feminist scholarship on psychiatry (Blum and Stracuzzi 2004, Busfield and Campling 1996, Chamberlin 1975, Chunn and Menzies 1990, Martin 1982, Plechner 2000, Smith 1975) uses a similar criticism of the validity of psychiatric diagnoses to that first posited in earlier critical studies of psychiatry as well as by various branches of anti-psychiatry, mad pride, and human rights groups and movements. These diverse individuals and organizations generally agree that the knowledge and experience of madness arises not from individual medical abnormality, but from the cultural, economic, and power structures of the society in which “mad” behaviour occurs (Becker 2000, Caplan 2006, Elden 2006, Foucault 1965). Thomas Szasz, one of the most vocal figures in the struggle to challenge the psy-ences monopoly on the definition of human “normalcy” or “abnormality”, was the first researcher to draw a parallel between the past phenomenon of “witchcraft” and the labeling of women as witches, and the newer phenomenon of diagnosing women as “mentally ill”, arguing that both concepts have functioned to define acceptable female conduct and provide punishments for deviance, now often in the form of medical “treatment” (Szasz 1974:182-198). Many other social researchers offer different analyses of the same parallel (Chodoff 1982, Foucault 1965, Turner and Edgley 1983). Since the topic was first publicized, feminist scholars have examined the conditions and processes that allow women to be deviantized and regulated in the name of “mental health”, although the social consensus on the legitimacy of this concept is so pervasive that merely raising questions about its meaning, use, or the industry that draws power from it may cause the culprit to be labeled as “crazy” (Chamberlin 1975, Chunn and Menzies 1990, Kaplan 1983, Lerman 1996, Smith 1975).
The Diagnositc and Statistical Manual of Mental Disorders (DSM), a publication of the American Psychiatric Association (APA), serves as the “psychiatric bible” (see Kutchins and Kirk 1998) of mental disease, and defines the criteria for an ever-increasing number of disorders. The DSM-I was 130 pages long, listing 106 disorders. Now in its fourth edition, the DSM-IV is 886 pages long and lists 297 disorders, nearly triple the number it did in its first (Grob 1991). It is the standard enchiridion used by all psychiatrists and other clinicians as a tool to diagnose patients. The validity of all DSM epidemiology has been challenged (Kutchins and Kirk 1998, Rose 1986), but the specific category that will be discussed in this paper – the Personality Disorders (PDs) – bear the least resemblance to physical ills, use particularly vague and highly interpretive language, and transparently reveal their usability as a tool in the pathologizing, oppression, and social control of women. This paper will focus on the three personality disorders that are almost exclusively diagnosed in women (APA 1994): Histrionic Personality Disorder (HPD), Dependent Personality Disorder (DPD), and Borderline Personality Disorder (BPD). The criteria for these “disorders” listed in the DSM (see Appendices A-C) describe gender stereotypical behaviour, caricatures of female roles in late-modern society, as well as common responses to oppression.
2. Theoretical Concepts
a) Feminist Theory: Gender Stereotypes and the Double Bind
The socialization of children from infancy reflects and perpetuates gender stereotypes (Nehls 1998:98). As outlined by many social theorists from Parsons (Parsons 1951) to Smith (Smith 1975), females are associated with “expressive” behaviour and “communion”, while males are associated with “instrumental” behaviour and “agency” (Becker 1997:39). Young boys are taught to be autonomous and aggressive, while little girls are taught to be dependent and passive. Reinforcement of gendered behaviour is powerful, accomplished through differential treatment and a complex system of informal and formal rewards and punishments, entrenched in nearly all social interactions. The traits assigned to girls and women are ones that our society devalues, thus females are inductively devalued, leading to differential treatment and negative experiences, including having a greater chance of being diagnosed with a psychiatric disorder, especially when these traits are exaggerated.
Gender typing is blatant in the PDs, even without examining their specific criteria. All ten disorders are grouped into three “Clusters”, which at a glance reveal some commonly held stereotypes about men and women. Cluster A, which contains only disorders diagnosed most frequently in men (Paranoid Personality Disorder, Schizotypal Personality Disorder, and Schizoid Personality Disorder), is defined under the heading “odd or eccentric behaviour”. Meanwhile, Cluster B, which contains BPD and HPD, uses the heading of “dramatic, emotional, or erratic behaviour”, and Cluster C, into which DPD falls, is headed “anxious or fearful behaviour” (APA 1994). The cluster solely occupied by disorders most commonly attributed to men lacks any reference to emotionality, while the other two focus on emotions, labeling them as problematic. While schemas of hegemonic masculinity discourage males from expressing emotion, women are associated with emotionality, and here they are pathologized for the expression of too much.
An analysis of the criteria for the three PDs, demonstrates that they constitute a spectrum of culturally prescribed, “acceptable” female behaviour – for example, one must not be too dependent on a male companion, as is described as a behaviour characteristic of DPD, but must also not partake in unserious relationships, a listed criterion for both HPD and BPD. A norm – a socially shared standard regarding culturally appropriate and desirable conduct – is defined. A woman should “settle down” with a monogamous partner, but should not rely too much on him. In society at large, women and girls are penalized for both conforming and failing to conform to standards of “appropriate” female behaviour. This paradoxical situation constitutes a “double-bind” – a circumstance in which one receives such contradictory messages, and that differs from a so-called “catch-22” or “no-win situation” for two reasons: 1) the affected individual is largely unaware of its existence, and 2) it resonates from a person or institution that the individual respects or trusts (Brown and Ballou 2002). All women in our society are confronted with a double-bind – they may either conform to “proper” feminine conduct, reinforcing their subordination and powerlessness, or they may rebel by adopting supposedly “masculine” traits such as independence, and face chastisement and alienation. Both choices may merit a psychiatric diagnosis, and the more “extreme” one’s conduct is, in either direction, the more likely it becomes that she will encounter sanctions.
Kaplan (Kaplan 1983) provides the first feminist critique of the personality disorders in 1983, arguing that certain PDs – HPD and DPD, with the addition of “Avoidant Personality Disorder” (APD) – may be seen as caricatures of the traditional female role, and may be used to punish women who over- or under-conform to gender norms. In addition, the DSM defines the consequences of the PD as “either significant impairment in social or occupational functioning or subjective distress” (APA 1980 as cited in Kaplan 1983:788), not allowing room for the possibility that the “disturbance” in question is brought about by a conflict between the individual and society, and is not indicative of “impairment”. Kaplan mentions BPD but does not examine it substantively. Since her published research regarding her perception of gender-typing in the personality disorders, collected during the five years directly following the release of the DSM-III, BPD has become the single most diagnosed PD; it will be subject to extensive examination in this paper.
Women represent the Other in psychiatric discourse (Rimke 2003, Smith 1975) – unstable compared to the “rational norm” (Wirth-Cauchon 2001:39). Our culture’s binary logic, dualistic and hierarchical, is at work. “Female” traits are not only devalued and placed in a subordinated position, but have been medicalized and pathologized, as is evident in the PD criteria. The Cartesian subject embraced by our society values thinking over feeling, which is associated with the feminine, and pathologized in psychiatric discourse.
Conrad and Schneider define medicalization as “the defining and labeling of deviant behaviour as a medical problem, usually an illness, and mandating the medical profession to provide some type of treatment for it” (Conrad and Schneider 1980:29). The increasing intervention of the medical establishment in the everyday lives of individuals achieves social control and moral regulation by limiting, modifying, regulating, isolating, or eliminating deviant behaviour with medical technologies, and in the name of “health” (ibid.). A hybrid discourse emerges, as medical jargon seeps into everyday discussion about problems of living, and phenomena that were never before associated with medical “cures” are reconceptualized using medical terms (Dworkin 2001, Rimke and Hunt 2002). This sociological perspective on medicine and disease differs from mainstream conceptions of illness which include: 1) the positivist position, similar to the “commonsense” view, that illness is a disease that impairs the good functioning of an organism, and that these illnesses are entirely objective, and 2) the phenomenological viewpoint that postulates a body/social dichotomy, arguing that disease is a physiological state while illness is a social state, presumably caused by a disease (Conrad and Schneider 1980:30). The latter perspective provides insight into the different interpretations of certain physiological presentations among different cultures – while in our North American culture teenage acne is a disease to be medicated with various potions, some societies in South America may view the same physical presentation of acne as a beautiful sign of coming of age.
Although these cultural investigations and comparisons are helpful in illustrating the variance between discrete societies and challenging local hegemonies, the sociological perspective takes on a more inquisitive and critical stance, stating that both “disease” and “illness” are purely human constructions that emerge from the authoritative and powerful medical establishment, which are then introduced to the common population, and come to be seen as representations of truth and reality among laypeople, further validating medicine’s claims and reinforcing the power and privilege of medical science (Hacking 1999, Murphy 2001). Illnesses are negative social judgments that immediately affect the behaviour of the diagnosed individual, and the meaning of illness is socially defined, independent of any biophysical state (Conrad and Schneider 1980:31).
The case of “mental diseases” elegantly demonstrates this process, as their biophysical basis – now usually cited as stemming from a “chemical imbalance” in the brain – is sketchy at best. They are entirely socially defined – first by a few powerful members of the psychiatric establishment, and then by society at large (see Turner and Edgley 1983). Individuals labeled as psychologically “sick” begin to adopt the “sick role”, a role defined by social expectations (Parsons 1951). After the assignment of a label by a medical authority figure, he/she is removed of certain responsibilities and comes to be seen as someone who needs to be “looked after”. Since “sickness” is essentially undesirable, the individual develops a desire to “get better”, and thus turns back to medical technicians, blindly co-operating with the instructions he/she is given in the hope of getting well.
c) Foucauldian Theory: Authority, Power, History, Governmentality
Foucault’s analysis of psychiatry, and his resulting exposé of the great power the psychiatric establishment and the psy-ences have been granted, to the extent that they have a monopoly on the definition of “normality”, is crucial to critical studies of psychiatry (Foucault 1965, 2006). Two other Foucauldian concepts and their resulting theoretical and practical tools will be used in this genealogical paper. First, is the importance in constructing of a “history of the present”, the “genealogical” method, to gain insight into the historical, discursive accomplishments, that originally gave meaning to the words and concepts we now take for granted (Foucault 1977b). The genealogical method inevitably reveals patterns in discourse, institutions, and practices in temporally discrete societies, often leading to the controversial conclusion that society has not “evolved” over time, but has remained largely the same, merely describing the same ideas and values in new language to suit the times (Wodak and Meyer 2001). The institutions granted authority and power may change, but very often, their regulatory projects remain the same (Foucault 1977a).
Second “Governmentality”, is vital in the examination of the social and moral regulation of any subset of the population in late-modern/postmodern society (Castel 1991). Governmentality describes the social condition where individual members of society voluntarily govern themselves, and the centralized Government no longer needs to take coercive measures to ensure the obedience of the citizenry. A multiplicity of supposedly independent, objective, and benevolent institutions take over this task by fostering self-discipline and docility. The governance of our mentalities takes place as our minds and ideas are shaped by schools, hospitals, prisons, et cetera, and indeed, the psychiatric establishment (Foucault 1978). The “self-diagnosis” technologies by which individuals may “discover” the source of their discontent in their own “pathological” behaviour, thinking, and feeling, initiating on their own involvement with psychiatry, may be seen as a stark example of the phenomenon of Governmentality.
d) Hacking’s “Looping Effect”
Once included in the DSM and given the status of an official category of illness, a diagnosis takes on a life of its own, and not necessarily one anticipated or intended by its original developers. Ian Hacking terms this phenomenon the “looping effect” (Hacking 1999). He explains that there is a fundamental difference between the scientific labeling of objects or “indifferent kinds”, and that of human beings or “interactive kinds”. While the former remain essentially unchanged regardless of the labels assigned to them, humans react immediately upon being labeled, altering their behaviour in ways that cannot be anticipated. Their reaction stems from their beliefs about their new classification, and the treatment they receive from the “users” of this classification – both professionals and lay-persons. As their behaviour changes, the relevant knowledge forming the basis of the classification changes in response, which again produces new behaviour, and so on (Murphy 2001:145).
After the classification of just one individual, they become no longer identical to the individuals studied in order to create the classification. “Expert” theory and lay opinion interact and change one another (Sparti 2001:334). Thus, while each “new discovery” touted by psychiatry and added to new editions of the DSM in the form of a new diagnostic entity appears to reflect an objective accumulation of knowledge, expert observation of particular characteristics must come from a lay understanding of what “that sort” are like (Murphy 2001:157). The Personality Disorders reflect not only “expert” judgment, but the reactions they have elicited upon use, among pathologized individuals, their relations, and within popular culture and discourse. Stereotyping, stigma, and social rejection are not only sparked by psychiatric diagnoses, but with time their negative effects come to define the diagnoses, validating and perpetuating a repressive system and an oppressive environment for deviant women labeled with a personality disorder, and for all humans who are determined to be mentally diseased by a psychiatrist.
e) Neo-liberalism: The Year 1980
1980 – the year of the publication of the DSM-III, with its “revolutionary” diagnostic framework – was ushered in alongside new social and economic policies, and a strong revival of neo-liberal ideology. With the election of Ronald Reagan in the United States, Margaret Thatcher in the United Kingdom, and Brian Mulrouney in Canada, social programs were replaced by the dogma of the omniscient “free market”, as Reagan touted the virtues of a system where wealth simply “trickles down” from the top – with the increasing privatization of industries formerly regulated by the government, the rich would get richer, and therefore the middle and lower classes, somehow, would as well.
The laissez-faire economic and ideological climate was accompanied by changes in social relations and values. The somewhat collectivist cultures and subcultures of the 1960s and 1970s were replaced by total emphasis on the individual, who was ultimately the only one responsible for his or her own circumstances – financial, social, and mental. The new hyper-responsibilization of the individual gave way to institutional changes that remain intact today, and which accommodate governmentality by promoting self-regulation. In the field of psychiatry, the DSM-III marked a near total break with the discipline’s psychoanalytic roots, which sought to extensively examine the context of an individual’s life, shifting instead to a pure focus on individual pathology. The new manual allowed for quick and easy diagnosis, via series of checklists outlining “symptoms”, their causes located in the psyche of the patient, thus leaving environmental and social conditions undiscussed. New demands for efficiency changed the patient-therapist relationship on one hand, but also led to the phenomenon of the individual voluntarily and avidly seeking to find some pathology within oneself, which if remedied, held the promise of increasing one’s efficiency and consequent success as a human being. The cultish trend of self-diagnosis had begun, and its primary consumers would be women.
3. The Disorders: Borderline, Dependent, Histrionic
Hard to hold, cold to touch,
Fall to pieces, treat the rush,
In hindsight, with prime time talk.
All your pain will end here.
Let the doctor soothe your brain, dear.
(Haines, Emily. “Doctor Blind”)
Trull and Widiger, simplifying the wordy DSM conceptualization, define personality disorders as “pathological manifestations of normal personality traits” (Trull and Widiger 2003:149). It is the psy-establishment’s privilege to determine when a “normal personality trait” has somehow crossed a line and ventured into the realm of “pathology”. The DSM uses the vague and highly interpretive descriptor “inappropriate or intense” in the criteria for all three of the notoriously “female” personality disorders (APA 1980, 1994). Thus, it logically follows that “normal” womanly traits – despite the contradictory fact that psy-entists contend “personality traits” fundamentally define the unique qualities and characteristics that form an individual’s distinctive character – may be expressed in an “inappropriate” situation or manner, or may become too “intense”. This last incredibly ambiguous descriptor could potentially entail an infinite number of “problematic” scenarios, arbitrarily labeled as such according to the quick judgments of a psychiatrist: does the extreme expression of these traits push the patient towards the dangers society associates with “abnormality”?; does their intensity lead to “immoral” conduct?; do the intense expressions overpower other, more appropriate features of one’s personality?; do they begin to influence the course of one’s life in a negative way, or perhaps a positive way that a doctor judges otherwise?; are they causing an annoyance to others, or eliciting disapproving glances from strangers?; are they resulting in the embarrassingly loud communication of socially subversive ideas?; do they cause one to yell or cry or shout in elation in public?
The very definition of a PD grants medical doctors, scholarly psychologists, and unaccredited psychological entrepreneurs a legitimate monopoly on the determination of who is “abnormal”, should be officially labeled as such, and requires “adjustments” to their distinctive and unique qualities. Abnormalities of the female personality appear to be so uniform and predictable that they almost always are caused by one or more of three mental diseases. If a woman, because of the personality that makes her distinguishable from any other human being, fails to conform to rules regarding socially acceptable femininity, she must be conforming instead to one of the DSM’s lists of symptoms. Conformity is evidently inescapable.
Each of the personality disorders diagnosed almost always in women – HPD, BPD, and DPD (O’Donohue et al. 2007) – may seem like a caricature of certain fabled women of the past and present, and are even presented this way in medical texts, as we will soon see. When combined, their criteria constitute a continuum of acceptable female behaviour – it is not surprising that each of these disorders is co-morbid with one another, but not with other PDs.
As BPD has become the most frequently diagnosed personality disorder, it is the topic of much more research, discussion, and zeal, both within and outside of the psychiatric establishment. However, these three disorders must be examined as a set, as they have influenced one another’s criteria, and together they reveal much about the moral regulation of women, and both changing and unchanged role expectations for females. The official DSM criteria for the three disorders can be found in Appendices A, B, and C, on pages 55 to 58. The processes leading up to their crystallization in 1980 also demonstrates several ways in which the psychiatric establishment uses language to legitimate its claims.
The most commonly diagnosed, culturally recognized, and increasingly controversial disorder, BPD, grew from much different concepts than those that define it today. The term “borderline” was first used by analyst Adolf Stern in 1938 to describe patients who were sicker than “neurotics”, but not as ill as “psychotics” (Shaw and Proctor 2005:486). The “border” concerned was that between agitation and schizophrenia, and “borderline” indeed became a popular term used to refer to patients who seemed to exhibit a more “mild” form of schizophrenia – gendered behaviour was of no concern under this usage of the term “borderline”. The expression became quite contagious, and was soon also used casually by members of the psychiatric community to refer to a variety of conditions, until the mid-1970s, when exceedingly influential psychiatrist and APA board member Kernberg decided to redefine “borderline” as a more specific syndrome. Calling it “a level of personality disorganization descriptive of the most serious form of character pathology”, “borderline personality organization”, primarily affecting women, was characterized by a weak concept of self, anxiety leading to impulsivity, emotional instability, sexual perversions, and the use of primitive defense mechanisms such as “splitting” – viewing others as entirely good or entirely bad, with no “grey area” (Zanarini 2005:9). Its chief cause was located in “inadequate mothering”, alleviating men of any responsibility and doubly pathologizing women. In this case, language familiar to clinicians was used to describe a newly conceptualized disorder.
BPD is now the most common PD diagnosis, and is increasing in prevalence in comparison to non-PD diagnoses (Shaw and Proctor 2005:483).
In defining HPD, rather than using an old term to package a new disorder, a new term was used to refer to an old disorder. Both of these techniques are commonly used to propagate scientific legitimacy, distracting attention from the very sketchy scientific bases of the PDs as well as the other disorders outlined in the DSM. Technical sounding labels created by the powerful and trusted medical establishment, previously unknown to the public, are uncritically accepted, as people assume that their creators have superior knowledge of the human body and mind, and that non-scientists simply cannot understand such complexities or the terminology used to describe them. The public puts their trust and faith in medicine and its “experts”. Just as with each publication of the DSM a host of new disorders emerge, old disorders that have fallen out of favour often appear repackaged, disguised by the use of new language (Cermele et al. 2001). A salient and more notorious example of this process is another condition reserved for women, whose name has been changed from “Pre-Menstrual Syndrome” in the DSM-II, to “Pre-Menstrual Dysphoric Disorder” in the DSM-III, and finally to “Late Luteal Dysphoric Disorder” in the DSM-IV (APA 1968, 1980, 1994).
Recent research on HPD, in anticipation of the release of the DSM-V in 2012, completed by psychologists Blagov, Fowler, and Lilienfeld introduces the disorder by offering a particularly shameless stereotype to conceptualize the condition, asking one to “ponder the nature of superficially dramatic, manipulative, and insatiably attention-seeking characters such as Blanche DuBois in Tennessee William’s play A Streetcar Named Desire.” (Blagov et al. 2007:203) This use of fictionalized characters as “textbook” cases of all three PDs proves to be a motif upon examining the clinical literature. Now wearing the guise of new and more “scientific” language, HPD is simply a new name for the disorder formerly called “hysteria”.
While hysteria was originally linked to female weaknesses arising from their biological sex, accompanied by physiological problems with one’s reproductive organs, Freud and fellow psychoanalysts pushed the cause towards the psychical phenomena of “penis envy” and “castration anxiety” (e.g., Freud and Bruer 1895). Both of these conceptions cite the same cause – hysteria is an illness essentially resulting from not being a man – pathologizing womanhood itself (Didi-Huberman 2004). The DSM-I included a condition called “hysteria”, while the DSM-II adopted the term “hysterical personality”, moving it into the category of personality-based disorders. In the DSM-III the word hysterical is dropped and “histrionic” is adopted, derived from the Latin “histrio” meaning “actor”, denoting the same melodramatic theatricality ascribed to hysteria, but without the old term’s baggage. (Blagov et al. 2007:206-207).
The original DSM-III (APA 1980) criteria for HPD overlapped markedly with those for BPD, including “irrational, angry outbursts or tantrums” and “proneness to manipulative suicide attempts”. The DSM-III-R (APA 1983) eliminated these similarities, assigning anger and manipulativeness exclusively to BPD, and adding to HPD “inappropriate seductiveness” and “impressionistic speech”. A proposition made in anticipation of the DSM-V, not yet “empirically” tested, is the inclusion of “pseudohypersexuality”, implying that individuals with HPD, actors that they are, “act out” overt sexuality, while avoiding true intimacy and remaining sexually unsatisfied (Blagov et al. 214). If included in the DSM-V, this would entail a throwback to the earliest notions of hysteria, rooted in ideas about the sexually unsatisfied female, and which for a time was treated by doctors by applying a vibrating device to the patient’s intimate parts. The pathologization of female sexuality has been a key device in the social regulation of women, utilized long before psychiatry existed. This issue will be explored in detail in the next chapter.
Although pathological dependency was outlined in the DSM-I, influenced by Freud’s concept of “oral fixation” and its consequences, it was given the status of a personality disorder until the publication of the DSM-III, which defined it using three broad symptoms, particularly vague even according to typical DSM rhetoric: 1) passivity in interpersonal relationships, 2) willingness to subordinate one’s needs to those of others, and 3) lack of self-confidence. The DSM-III-R included much more detailed criteria, which were carried over verbatim to the DSM-IV (see Appendix C). As DPD is the least diagnosed of the three disorders, its criteria have not been subject the amount of research expended on the other two.
Two prominent and influential psychological “models” of the DPD are the “cognitive model” and “ the behavioural and social learning model”. The former cites its cause to be a pathological inner monologue in which “negative self-statements” lead to a vicious cycle, reinforcing and amplifying feelings of helplessness. The latter attributes responsibility to one’s primary caregivers during infancy and early childhood – most often emphasizing again the mother’s role – for rewarding dependent behaviour, and thus causing one to behave dependently in other interpersonal relationships later in life, consciously or unconsciously anticipating a similarly positive reaction (Bornstein 2007:310).
Bornstein, the chief psychiatrist working on revisions to the DPD criteria for the DSM-V, has proposed this series of amendments: 1) explicit reference to the previously mentioned “cognitive” processes that produce the pathology, 2) the removal of symptoms three and four, and 3) their replacement with two symptoms he believes are more empirically valid – “uses a variety of self-presentation strategies (ex/ ingratiation, supplication, exemplification, self-promotion) to obtain and maintain nurturant, supportive relationships” and “focuses his or her efforts on strengthening a relationship with the person most likely to be able to offer help and support over the long term” (Bornstein 2007:317). If adopted, it seems it would be fair to charge the same women’s magazines that created the personality quiz for being responsible for the mass-production of symptoms of DPD in their readership.
One of the most cited concepts in the field of women’s and gender studies, mentioned earlier as an important theoretical framework, is the differential socialization of male and female children. While boys are encouraged by agents of primary and secondary socialization to be independent, are given less assistance when learning new tasks, and are comforted less when crying or frustrated, girls are coddled more, helped more, and encouraged to rely on others for emotional, physical, and psychical needs, ultimately teaching them to be, to a certain degree, dependent. Thus, it is not surprising that most of the individuals who psychiatrists judge to have ventured into the realm of “pathological” dependency, are women.
A number of studies (e.g. Cross et al. 2000, Padilla 1995, Trull and Widiger 2003), conducted since the publication of the DSM-III, demonstrate the gender- and culturally-bound nature of the personality disorders, as well as their markedly unscientific foundation. Three patterns illustrated by these studies pose a challenge to the validity of the illness categories of BPD, HPD, and DPD: 1) the issue of co-morbidity between these disorders, 2) their relationship with other personality disorders that are diagnosed most frequently in men, and 3) their very different rates of occurrence in non-North American countries, where different personal traits are culturally valued.
Co-morbidity, the statistically significant co-occurrence of one disorder with another is more of a rule than an exception in the DSM, and following its discussion of the criteria of each disorder is a list of other disorders that commonly accompany it. A number of studies conducted in the 1980s demonstrate significant co-morbidity between the three “female” personality disorders. As well, leading up to the DSM-III, drafts of the HPD etiology included the notion that the condition was characterized by dependency. Evidently, this idea was dropped from the publication to reduce the overlap between HPD and DPD. This change, like so many to the DSM, was based not on any science, but was a matter of convenience to its authors, making their framework look more concise and less complex than the truth would. There is still much debate in the field about the possibility that “dependency” underscores HPD, and motivates the behaviour manifested in its symptomatology (ibid). Not surprisingly, the current edition of the DSM lists all three disorders as co-morbid with one another.
Though not examined in detail in this paper, several other personality disorders are diagnosed far more often in men, the most extreme example being Antisocial Personality Disorder (APD). Sex bias in the diagnosis of HPD and APD emerged to be strikingly significant in a study carried out by Ford and Widiger (1989). The researchers obtained a series of case histories of patients with APD, HPD, or balanced features, and the sex of each patient was “female”, “male”, or “unspecified”. When a case was consistent with the features of APD, it was diagnosed much more frequently in men (42%) and the unspecified gender (48%) than in women (15%), who were instead diagnosed with HPD (46%). When a history of HPD was raised, it was diagnosed at extremely high rates in women (76%), at lower rates for unspecified gender (68%), and lowest in men (44%). Such findings have led some “experts” to propose that APD and HPD are gender-typed forms of the same condition (Blagov et al. 216). Indeed, both are characterized chiefly by a profound need to be noticed by others, but according to the DSM their goals are different – the goal of the individual with HPD is emotional connection with others, while her/his counterpart with APD seeks material and vocational gains. These respective motives may be seen as a vivid reflection of traditional gender roles.
The critics of all ten DSM PD categories, effectively silenced by the behemoth of mainstream psychiatry, include scholars such as Gove and Tudor (Gove and Tudor 1977), who argue that all of these categories merely describe behaviour that does not conform to social norms, as well as grouping dissidents into different categories by gender (Becker 1997:39). The uniformly “male” category of APD is also compared with BPD. Like in the case of HPD, many criteria for each disorder describe nearly identical conduct; listed under APD are manipulativeness and deceitfulness, impulsivity, and “aggressiveness” – the word “anger”, underscored in the definition of BPD, is curiously absent from the description of the evidently “masculine” disorder. Again, the two disorders differ in terms of their stated social consequences. BPD is described exclusively in terms of its leading to instability with regard to relationships and self-image, while APD is said to lead to failure to honour work and financial obligations, and a “disregard for the safety of the self (and others)” (APA 1994). The most important social norms to adhere to on the basis of one’s gender are made very clear.
The specific pathologizing, and medicalizing, of female “anger”, as opposed to male “aggression”, demands further inquiry. Each of these three personality disorders focuses on a certain type of pathological female “emotionality”. HPD broadly pathologizes “exaggerated emotionality and theatricality”, DPD pathologizes “fearfulness and helplessness”, and BPD is granted responsibility for pathologizing female “anger”, whether it be “inappropriate”, “intense”, or “difficult to control”.
Within popular knowledge, that to which Hacking attributes great influence in the constant redefinition of diagnostic categories, the most recognized feature of the “borderline” woman is anger, often colloquialized as “borderline rage”. The word “rage” is ominous, implying an eruption of anger that has been held back, before finally exploding (Wirth-Cauchon 2001:169). Society encourages women to suppress anger – yelling is unladylike and a woman’s screams are still “hysterical” – thus, most expressions of anger by females may be classified as “rage”. Feminist scholars examining psychiatry have taken up the topic of pathologizing women’s anger, much of which stems from their subordinate position in a patriarchal system. The terms “inappropriate” and “intense” irrationalize and depoliticize female anger, making it “crazy”. Becker calls BPD a “rhetorical accomplishment” that portrays women’s anger as an “overwhelming, irrational force” in need of intervention and control (Becker 1997:121).
Ironically, according to most disciplinary literature, anger is recognized as a positive force that can be channeled into productive pursuits. Yet the same discipline tells women that their anger is irrational, primitive, destructive, and must be smothered. Within this double standard, the overt fear that channeled female anger may pose a threat to the solidity of the current patriarchal order becomes palpable. By painting righteous female anger with the brush of insanity, its legitimacy is dismissed. A woman’s anger at expectations of passivity and submissiveness, directed at men (such as father, husband, or psychiatrist), indicates that there is “something wrong with her”. To be a “normal” adult woman, one must be content in her subordinate position, or at least appear to be.
Finally, further evidence from studies completed over the past two decades speaks to the culturally-bound nature of the personality disorders. Although a sufficiently large study has not been carried out, authors such as Johnson (Johnson 1993) and Padilla (Padilla 1995) hypothesize from a smaller sample that HPD is diagnosed less frequently in Asian countries, and other cultures that discourage overt sexualization, but more often in Hispanic and Latin American countries where a more overt sexuality is the norm (ref – 213). While geographically isolated cultures are usually the subjects of these studies, one may also consider changes that take place within a culture over time, such as those in North America and the United Kingdom during the early-1980s, including but not limited to neo-liberal reforms. Thus, one may infer that HPD “exists” in our North American context at least in part as a result of characteristics of this culture – a consumerist one, that to a certain extent demands these behaviours from women. It is undeniable that media, from women’s magazines to advertising to popular “chick flicks”, outright instructs women to donate much time and energy to perfecting their physical appearance (criteria 4), to follow certain mores in the seduction of male romantic interests (criteria 2), and to expect intimacy and commitment from a partner after a short courtship (criteria 8). A new conceptualization of HPD put forth by Westen and Shedler in 1999 even suggests including the new criterion of “fantasizes about finding ideal, perfect love” (Westen and Shedler as cited in Blagov et al. 2007)- an ideal that is undeniably perpetuated ad nauseam by media directed at women.
Psy-experts who subscribe to the “attatchment perspective” on mental disorders propose that HPD is consistent with a “preoccupied attatchment style”, in which one maintains a positive mental model of others but a negative model of the self. Again, the standard female ideal portrayed quite obsessively in the media may produce this effect. No studies have examined this correlation.
Since BPD has become so prominent, the collection of studies on this specific condition include not only those conducted within mainstream psychiatry, but also some performed by critical feminist researchers, who have employed a few different research methods. Wirth-Cauchon’s work, the most widely recognized research on the topic of feminist studies of BPD, analyzes the commentaries of therapists and their clients from feminist and postmodern perspectives (Ross 151). Cermele et. al. subjected the DSM Casebook to content analysis that revealed consistent differences in the language used to describe female or male patients, often reflecting oppressive conceptions of femininity. A few quantitative academic projects using questionnaires have also been carried out. Sprock and Morey et al. both surveyed males and females, asking them to rate criteria, secretly taken from DSM PD criteria, on a few bases related to gender. Neither study revealed significant differences between the responses of men and women, and both researchers concluded that DSM PD criteria were not at all biased towards men or women (Morey et. al.). However, both studies overlooked some important factors: the effect of demand characteristics in the questions, the inherently gendered nature of the criteria themselves, the larger patriarchal system in which both males and females exist and in which women pathologize their own behaviour, and the possibility of differential pathologizing of characteristics on part of the diagnostician when displayed by different sexes. Thus, more intensive, critical, and substantial research is badly needed.
Hacking’s concept of the “Looping Effect” is demonstrated in the definition and redefinition of all personality disorders, as the characteristics and conduct of diagnosed individuals is observed, and then becomes the basis for revisions to the DSM criteria. Popular knowledge about the disorders, especially that about BPD as it has grown to such notoriety, influences the behaviour of labeled women, and elicits particular treatment from others – both laypeople and experts – which in turn also has an effect on one’s conduct, initiating the cycle that Hacking describes. This process will be examined in detail in section five, which examines the role of popular culture and discourse in the advancement of the personality disorders. However, first the history of female oppression that underlies these disorders will be examined, in keeping with the Foucauldian argument that history is crucial if one is to understand the present.
4. History of Female Oppression: Witchcraft, Hysteria, Personality Disorders
Wait Mister. Which way is home?
They turned the light out
and the dark is moving in the corner.
There are no sign posts in this room
four ladies, over eighty
in diapers every one of them.
La la la, oh music swims back to me
and I can feel the tune they played
the night they left me
in this private institution on a hill.
The path from witchcraft, to moral insanity, and then to these “female” personality disorders – borderline, dependent, and histrionic – epitomizes the transfer of power and authority from religion to science that has taken place over the past several centuries. Each label from each respective era, granted “official” status by (consistently male) “experts” representing the absolute knowledge of the most prominent institution de jour and subsequently treated as fact, defines the boundaries between acceptable and unacceptable behaviour for women, with deviance often involving treading on the border between the masculine and the feminine (Wirth-Cauchon 2001:85-87). Each label initiates social control, as its application justifies some form of punishment and/or “treatment”. Using Foucault’s genealogical method and creating a history of the present by examining historical discourse – discourse being not only representative but formative – regarding the social regulation of women reveals patterns (Wodak and Meyer 2001); certain features emerge that essentially have not changed at all – what has changed is the institution legitimating the designation of the criteria for deviant womanhood that merits intervention, and the language used to describe them. The genealogical method allows us to better understand current society by gaining insight into the past, which leads to the realization that today’s regulatory projects bear close resemblance to those of other eras. The successful interruption of patterns of oppression can benefit greatly from the knowledge gained through a genealogical historical analysis.
This process and its usefulness are vividly illustrated in the example of pathologizing inappropriate romantic and sexual conduct for females. In the period preceding the European Enlightenment, a woman who lived alone, without a male companion with whom she could reproduce, or a woman who attracted too many men – proving to be “sexually crazed” on account of having “illegitimate love affairs” – could be quite sure of that she would be accused of being a witch (Usher 1991:49). Anchored on the absolute authority granted religious institutions, witches were suspected of and charged not only with disobeying gender norms, but with having sex with the devil. One may see the reflection that mirrors two social tenets that continue to permeate societal values and beliefs about women today: the link between female sexuality and both “badness” and “danger”, and the double-bind women face as they are criticized for both being too sexual or too “frigid”. Females who failed to conform to the expected roles of wife and mother were thus not only stigmatized and shunned, but were granted an official label that justified “correction” by corporal punishment, or upon its frequent failure, condemnation to death. Also charged were female healers, who made the fatal mistake of encroaching on the rising, decidedly male, and thus patriarchal, field of medicine.
The “DSM” of Witchcraft, the Malleus Malificarum, a highly sexual text that named signs that a woman was likely a witch, not unlike the diagnostic criteria named in the modern DSM. The book was a mainstay in most houses even though most of their residents were functionally illiterate, its presence primarily symbolic, but anyone could make a formal accusation that a certain woman was a witch, initiating an investigation. Official diagnostics were handled by the “pricker” who, like his modern counterpart the psychiatrist, was granted the power and privilege to enter any village and subject any woman to a test – not a test of her sanity, but of her spiritual health, as a prick of the finger was believed to cause a certain amount of blood loss depending on whether or not one was involved in dealings with the devil (Usher 1991:53). The pricker could involuntarily commit any woman who, in his eyes, failed the test – a tradition carried on today by the psychiatrist, armed not with a needle but with lists from the DSM, series of questions with correct and incorrect answers believed to determine whether one is “mentally ill”, and a cornucopia of psychopharmaceuticals to prescribe at his/her discretion (see Healy 1997).
The fortunate women who were charged with witchcraft but who escaped execution received “therapy” from the “experts” on these matters in their era – exorcists and spiritual healers – giving them a second chance to conform to behavioural expectations for females, thus rendering one “healed”. Therapy, born in the confession booth, became a device for perpetuating a patriarchal system, ensuring that gender roles and hierarchies were maintained, masked by claims of altruism and improvement of women’s quality of life, while really serving to preserve a social order built on female subordination. If the “therapist” failed to “cure” a woman of her evil tendencies, their inability to do so was attributed to the recalcitrant evil spirit – later traded for the recalcitrant “illness” (Usher 1991:44).
During the Enlightenment, the use of death as a deterrent fell out of favour in the West (see Foucault 1977a), but the deviantization of women who violated the codes of hegemonic femininity continued. Witchcraft was first linked with madness by Johann Weyer in 1563, but the comprehensive transition from witchcraft to hysteria began at the dawn of the 19th century, with “Father of Psychiatry” Phillip Pinel declaring that “demonics of all description [were] to be classed either with maniacs or with melancholics” (Pinel as cited in Usher 54 1991:44). Foucault argues that the concept of hysteria emerged in the early 1800s as a new word for men to use to describe “difficult” female behaviour in the absence of “witchcraft” and suiting the societal shift from belief in religion to belief in science (Foucault 1965).
A medical term that emerged alongside hysteria, “moral insanity”, uses language highly illustrative of the periodic struggle between religion and science. The “Doctrine of Moral Insanity” as outlined by Prichard attempts to create a hybrid philosophy and programme based on the premise that immorality has a biological basis (Rimke 2009:13). Proponents of the doctrine appropriated the new, faith-breaking discoveries of evolutionary biology to construct an argument that the existence and procreation of humans of poor character who partook in immoral acts, would lead to a catastrophic degeneration of the evolutionary sequence, as immorality was a function of individual biology. The creation of moral insanity gave nineteenth-century scientists a monopoly on the resolution of moral dilemmas, and they came to be seen as “experts” on debauchery of all kinds – of course without participating in it themselves – who could serve as a benevolent force amidst the rapid social change and disintigration of traditional forms of regulation and solidarity, accelerating with modernization.
Set against the backdrop of disruptive change, which included the triumph of secularism and the metastatis of capitalism, a human science rose that offered the shining promise of being able to solve the modern problems of living, such as crime and vice, as they could be traced to individual deficits or psychopathologies, and thus somehow systematically eliminated. Contemporary psychiatry is still based on this pipe dream, its authority and power relying on the premise that its “medical expertise” holds the key to solving social ills, one individual at a time (ibid.). Moral insanity may be seen as an intermediary between the old authority of religion and the new and increasing authority of science. Its ideals remain in the human sciences and psychiatric medicine. A more detailed analysis of hysteria, one of psychiatry’s first widely recognized mental diseases, reveals the contradictions, ignorance, and compliance in sustaining oppression that still defines the discipline.
The term “hysteria”, derived from the Greek word husterikos, which literally means “of the womb”; its use as an adjective began sometime during the seventeenth century. The establishment of hysteria as a medical condition in the middle- to late-nineteenth century (Foucualt 1965, Szasz 1974) allowed a much greater number of females to be pathologized (Wirth-Cauchon 2001:101). Witchcraft had focused primarily on women who defied standards of femininity, while symptoms that elicited a diagnosis of hysteria included fainting, “pains”, defective gait, insincerity, amnesia, difficulty breathing, migraine headaches, nervous coughing, difficulty eating, hallucinations, fever, loss of voice, unsociability, suicidal ideation, and boredom (Freud 1905:46-52). The clichéd statement that any female discomfort could be explained by “hysteria” is not an overstatement.
The ultimate importance of reason established during the Enlightenment and the new dichotomy between male rationality versus female emotionality, permitted all women to be associated with madness to some degree. As science, with its newly named “experts”, took the place of religion, female pathology was immediately reclassified, and both its symptoms and treatment were reconceptualized in a manner that fit the new ideology. The fact that the miscellany of symptoms attributed to hysteria seems quite immediately absurd today speaks to the blind faith that non-experts put in “medicine” and physicians, and the power this institution and their representatives gain in return. The deviant woman was medicalized and assigned to the new status of patient, subject to medical “cures” provided by men, whose biological constitution and affinity for “thinking rationally” made them the best candidates for the new medical positions to be filled by physicians (Maines 1998).
Science also strengthened the double-bind in conceptions of female sexuality, linking the womb and the brain, and medicalizing morality. Aside from the previously named random discomforts associated with the disease of hysteria, a more cohesive and concise conceptualization of the condition revolved around deviant female sexuality. Both sex outside marriage and “frigidity” were declared to be key symptoms of hysteria, the latter being more frequent and the subject of many more theoretical musings, including those of the first psychoanalysts. The lack of desire to participate in sexual relations was linked to three somatic reactions supposedly experienced by hysterics: 1) sexual excitement resulted not in pleasure, but produced unpleasurable feelings, a phenomenon termed “reversal of affect”, 2) the displacement of sensations, for example feeling heaviness on one’s chest instead of a gentle caress of one’s lips when kissed, and 3) the avoidance of sexually excited men, and feelings of repulsion upon seeing men expressing affection (Freud 1905:59).
Whereas promiscuity had long been very publicly condemned and punished, failure to desire and enjoy sex in the morally sound context of marriage was a more private misfortune, until it suddenly became a topic of public discussion upon being designated as a symptom of a “disease”. Although religious authorities and texts had preached for centuries about the moral obligation of a wife to obey her husband and submit to his every demand, sexual or otherwise, female sexual pleasure almost never entered into the discussion. Hysteria abolished this conversational taboo, but an understanding of female sexuality was not gained, it was merely regulated in a new way – a way that decreased the range of “normal” female sensations and behaviour.
Female victims traumatized by assault or rape were sent to the asylum – their failure to be aroused by male sexual solicitation still symptomatic of a “disease” – as were promiscuous women, and women who bore an illegitimate child. Medicine offered therapeutic treatments during which a physician would apply a vibrating device to the female patient’s genitalia to relieve anxiety, as well as the extreme of “cure” by clitoridectomy when other remedies failed (Maines 1998). It is difficult to fathom a rational explanation for the use of both procedures to resolve the same condition if it is indeed manifested in difficulty feeling sexual pleasure, as the former procedure causes a woman intense sexual pleasure, while the latter physiologically eliminates any possibility of experiencing sexual pleasure for the rest of her life. The electroshock machine had yet to be invented, but when it was, it was also used to treat hysterical women, whose symptoms again very often arose after being sexually violated and traumatized (Usher 1991:72). The experience of sexual abuse is a very common feature of the life-histories of present day women who are diagnosed with personality disorders (Kluft 1990), in one sample 42% of adult inpatients diagnosed with BPD had experienced abuse, a phenomenon that will be discussed in the final section (Brown and Anderson 1991:58).
Hysteria, like witchcraft and soon the personality disorders, afflicted single women far more often than married women, as “spinsters” fail to fulfill their destiny of being a wife, mother, and domestic labourer – thus, as they reject social expectations for women, the conclusion follows that they must be “crazy” – suffering from an illness of the mind. The “deprivation of male company” was widely accepted to be one of the key causes of hysteria, inside and outside of the medical community (Usher, 79: 1991). Yet lacking male companionship was also one of the most common “symptoms” of hysteria. The great authority granted medicine and its new subset, psychiatry, is demonstrated in its ability to cite the same phenomenon as a cause and a symptom of an illness without being questioned on grounds of validity. The same kind of circular logic may be found in current conceptions of personality disorders. One of the DSM-IV’s eight criteria for BPD is involvement in volatile relationships, while the intense emotional expressions of the borderline individual are said to cause him/her to have turbulent, unstable relationships.
Intense emotional expression was another of the most common and most discussed features of hysteria, with particular attention paid to the annoyance caused for others, a pattern we will continue to see as we look at the modern personality disorders. Like witchcraft, and despite its cause being cited in individual physiological pathology, hysteria was distinguished by its negative effect upon those around the hysterical woman, emphatically described in 1877 by psychiatrist Mitchell in his statement that “A hysterical girl is a vampire who sucks the blood of the healthy people about her” (Mitchell as cited in Usher 1991:76). Similarly, BPD, DPD, and HPD are defined in part by the trouble they cause for anybody unfortunate enough to be in the borderline’s, histrionic’s, or dependent’s path. Headaches for others are highlighted again and again in literature on these personality disorders, setting it apart from that on other psychiatric diagnoses such as mood disorders, which tends to focus on the afflicted individual’s suffering. These texts will be examined thoroughly in the next section. One text for practitioners explains that BPD “may not cause a problem for self, but for those around oneself” (Carlson et. al. 1977:64). Strong, outspoken women who dare to transgress the boundaries of socially acceptable femininity (Rimke 2003), have been and continue to be prime targets for psychiatric diagnoses, and with the publication of the DSM-III, women who are not strong or outspoken enough have been added to the hit list under the category of DPD. Expressions of protest, quiet or loud, against the narrowly conceived suitable roles for females are named as symptoms of illness.
Returning to historical investigation, as the twentieth century progressed, again women who did not assume the “proper” female sexual role of devotee to her husband and his desires was labeled, whether she suffered from frigidity, or engaged in promiscuity; resistance to hegemonic female oppression was pathologized and medicalized. By the early 1950s, due in large part to the discovery of the first anti-psychotic medication, psychiatry came to be seen as a field of medicine concerned with mental diseases, defined in the first edition of the DSM (1952), which quickly became psychiatry’s primary tool in its effort to prove itself worthy of consideration as a legitimate branch of medical science, by outlining discrete, empirical categories of illness just like those used to diagnose physical ailments.
In the DSM, references to “morality” disappear as discourse concerning normal and abnormal womanly conduct is dressed up in scientific terminology. As mentioned previously, the first two editions of the DSM (1952, 1968) respectively include the categories of “hysteria” and “hysterical personality disorder”, both of which are defined by a the more fundamentally “immoral” sexual affect of the shameless solicitation of sex with multiple men. Reference to difficulty for the afflicted to experience sexual pleasure is not included, perhaps because of the contradiction evoked.
The next significant shift, that that took place in 1980 upon the publication of the third edition (DSM-III), was facilitated by its new “multi-axial” system of diagnostics. The new framework required the clinician to assess a patient on five different “axes”, allowing the diagnosis of multiple disorders by assigning them to different levels. The second axis is devoted to personality disorders, cementing their medical legitimacy. While the crystallization of this new group was justified as a means to increase the conformity of application of the personality disorders by physicians, in practice it had the opposite effect (Brown 1992:215). The use of extremely vague and subjective language in the definition of the personality disorders allows almost any deviant conduct to be named as a “symptom” and used as criteria for one disorder or another, at the physician’s discretion.
HPD, shed of the history and negative connotations associated with the term “hysteria”, was now accompanied by the two new maladies of BPD and DPD, introducing yet another double-bind for women. Aptly described by one researcher as a mirror image of HPD, DPD is manifested in too much reliance on others, while BPD is marked by a periodic lack of loyalty to others and a “pattern of unstable relationships…”. Not surprisingly, sexual promiscuousness is also included in the criteria for BPD – this time under the heading of “impulsivity (in at least two areas) that is potentially self-damaging” (APA 1980).
This new set of disorders again exponentially increased the potential for pathologizing women with its widely varied cornucopia of signs of illness. For BPD alone, there are 93 possible combinations of criteria that may constitute a diagnosis (Becker 2000:423), never mind the infinite number of ways that the clinician may interpret the ambiguous terminology used to define these features.
Female rage as a response to social injustice has been regulated and suppressed throughout history by the same mechanisms that attempt to regulate female sexuality, and the disruption that might be stirred by the organization of several “angry” women has been diverted. First included in the concept of hysteria, and then concretized in the diagnosis of BPD, psychiatry has consistently deviantized angry females. The power of the institution of psychiatry, no doubt aided by the history of society’s treatment of women predating its existence, has been such a formidable regulatory mechanism that the gendering of anger pervades mundane, everyday life. When men yell they are “assertive”, perhaps sometimes “mean”; when women yell they are “crazy”.
To conclude, although witches are no longer feared, women who do not fit society’s mould for the proper, and indeed “normal”, female role, are still considered to be dangerous. Witches were thought to be able to remove a man’s penis with a particular spell (Usher 1991:49). In the context of modern phallocentrism, deviant women are accused of a more metaphorical potential to castrate men, threatening the hegemony of their dominant and powerful societal position. Evidently, the threat of the disruption of patriarchal society presented by subversive women has been subdued, often with the help of the popular media.
From the age of witchcraft to the age of Personality Disorders, various relics of popular media have helped to define acceptable female conduct, and warn of the dire consequences that may occur if one fails to comply with these standards. During the Middle Ages, even though most commoners could not read, no household was complete without a copy of the Malleus Malificiarum – in English The Witch’s Hammer – the official guidebook for the prompt detection of witchcraft. The book is profoundly sexual, and delivers graphic tales of the witch’s horrible deeds against innocent civilians, along with naming the plethora of signs by which a witch may be identified (Chesler 2005). The fact that most of its owners could not read the text perhaps amplified the moral panic over witches, as information was based on hearsay and embellishment, and mystification is one of the most effective instigators of fear and anger. The ensuing ambiguity surrounding clues one could look for to identify a witch, a popular one being “bizarre behaviour”, echo today’s ambiguous criteria for Personality Disorders in the DSM, which once more allow almost any woman to qualify if someone has the impetus to frame her.
After the witchcraft epidemic had ceased, such an explicit manual detailing inappropriate behaviour ceased to exist, but nineteenth century romantic literature played a similar role, with its clear-cut distinctions between “good girls” – who would be rewarded with a happy marriage to a faithful husband – and “bad girls”, who were mad in their transgression of feminine decorum – usually participating in promiscuous encounters and lacking the manners expected of a lady – and who were doomed never to be “happy”. Again, a pattern emerges – in both cases the deviant woman is guilty of a social crime and punishment is inescapable: in the first case she is involved in dealings with the devil, meriting probable execution; in the second case, she fails to follow “nature’s” intended path for a woman, resulting in mental anguish and a miserable life. The emergence of governmentality may be observed as popular culture is examined in detail.
5. Pop Culture: Propagating Legitimacy
Calling for my soul at the corners of the world.
I know she’s playing poker with the rest of the stragglers.
Calling for my soul at the corners of the world.
I know she’s playin’ poker with the rest, the rest…
And if your friends don’t come back to you.
And you know this is madness.
A lilac mess in your prom dress, and you say…
(Amos, Tori. “Liquid Diamonds”)
Some of the most revealing artifacts of discourse are those that emerge from popular culture. The representation of women in film, advertising, television, music, literature, and other mass media, both tells the story of societal conceptions and attitudes towards women in particular times and spaces, and reflexively reaffirms these values. These media and their messages are very powerful, as all individuals consume them on a daily basis, whether voluntarily or involuntarily. Upon the inclusion of HPD, DPD, and BPD in the DSM, caricatures of the new disorders, unvaryingly female, quickly appeared in various arenas of popular culture. Three will be examined here: film and television, self-help literature and literature for clinicians, and the more recent development of websites on the Internet.
a) Film and Television
Images of “madwomen” have long been a staple in mainstream depictions of females. Looking at the field of artistic expression, one may argue that while men become famous for a particular talent – writing, singing, philosophizing, et cetera – equally talented women often gain fame for being “mentally disordered”, their skills becoming a mere footnote compared to certain “abnormal” behaviours and deviation from hegemonic femininity; Some of the most notorious being women writers and poets of the first half of the twentieth century, including Sylvia Plath, Anne Sexton, and Zelda Sayre. Since then, with the rise of film and television, these images have been concretized and immortalized by personifying them in fictionalized accounts of “crazy” females.
In reference to these three personality disorders specifically, although elements of all of them may be observed, most depictions – and certainly the most recognized depictions – are centered on the most diagnosed of the disorders – Borderline Personality Disorder. Beginning in the 1980s, the well known cinematized tales of “Borderline Women” – even cited as accurate portrayals by many “personality psychology” textbooks directed at undergraduate students – have been Fatal Attraction, Single White Female, and Girl, Interrupted. On the small screen, the recent HBO blockbuster series The Sopranos also incorporates BPD in its plot.
The most infamous depiction of BPD, and the one most commonly referenced as an accurate example of the disorder in the aforementioned textbooks, is Glenn Close’s performance as Alex Forrest in the second most highly grossing movie of the 1980s (Larsen and Buss 2005:618), Fatal Attraction (Lyne 1987). Forrest is a powerful woman – not only is she self-sufficient due to a lucrative career in corporate law, but she is also attractive and single. She initiates an affair with another lawyer, family-man Dan Gallagher, played by Michael Douglas, after meeting him at a work function that conveniently coincides with his wife and daughter being out of town. Throughout the film, Gallagher is portrayed as the hapless victim to Forrest’s irresistible seductive powers and masterful manipulation abilities. Gallagher’s wife, a homemaker, acts as a foil to Forrest, the unmarried, professional female who is conveyed as dangerous, predatory, and by the movie’s end, evil. There are even several flaming trashcans constantly ablaze outside of her apartment building. After the two consummate their affair, Forrest’s originally capable and independent disposition disappears, and is replaced by a dependency on Gallagher so great that she slits her wrists when he attempts to leave her apartment after a love-making session – this is after the misbegotten couple have known one another for two days.
The rest of the film documents Forrest’s wild attempts to continue a relationship with Gallagher and destroy his “perfect” nuclear family – she fakes a pregnancy, phones his wife, and picks up his daughter from school. Inevitably, the only way to stop this madwoman is to kill her, which Gallagher and his wife do together in the last scene, rife with symbolism, after Forrest breaks into their home. Although BPD is not explicitly mentioned in the film, it is well known that Close’s character was intended to embody a typical borderline’s unstable personality and crazed behaviour. The film’s message seems to be that independent women lacking husbands are desperate to find a man, dangerous, not to be trusted, and likely suffering from mental illness. This theme became extremely popular during the Reagan era, and is the basis of other popular movies in the 80s and early 90s, including and Basic Instinct and Single White Female.
Single White Female (Schroeder 1992) tells the story of Ali – another shoulder-padded career woman of this period, but this time she plays not villain, but victim, after making the perilous choice to kick her philandering fiancée, Sam, out of her enormous Manhattan apartment, and advertise for a roommate. This is how she meets Hetti, a frumpy-looking girl, at least a foot shorter than her, with a weak self-image that we learn of quickly as she constantly belittles herself, while fawningly idolizing Ali’s stylish image. Ali, enjoying her sycophancy, invites her to move in. After throwing a tantrum when Ali spends a night away, accusing her of “abandoning” her, Hetti’s “borderline” tendencies first become clear. Her “abnormal” sexuality is revealed next, in a bizarre scene where Ali’s face turns to sheer horror after she happens upon Hetti masturbating feverishly. From this point, the film is rife with the subtle promotion of Christian values regarding sexuality and relationships, without any explicit reference to theology or its moral implications. She quickly decides to forgive Sam of his shortcomings, salvage her engagement, and lose the new roommate, but telling Hetti that she must move again only initiates her reign of madness and destruction that proves to be unstoppable. The master manipulator buys a puppy to stir Ali’s affections, but throws it out the window to its death when she finds herself home alone again on a rainy evening. The symbolism reaches new heights when Ali finishes a business deal with a male client, who then proceeds to try to force her to have sex with him, being under the impression professional females often secure business deals with sex – she narrowly escapes his crude advances, and unemotionally tells Hetti about the encounter. She only appears to be disturbed after Hetti calls the man’s house and threatens him a bit too forcefully.
The pin drops when Hetti appears with her hair dyed and cut identically to Ali’s, and wearing one of her power suits. When she leaves the apartment for the evening, Ali follows her, and discovers that she not only masturbates, but frequents some kind of “sex club”, complete with leather, leashes, and casual sexual encounters for public display, no engagement rings attached. Ali rushes home to go through Hetti’s belongings, and discovers a shoebox of photographs and notes that seem to indicate a vaguely troubled past, but with some reference to “doctors”, serving as proof that she is certifiably crazy and consequently dangerous. Meanwhile, Hetti leaves the club for a hotel where Sam is staying, sneaks into his room, and performs oral sex on him – her “new look” so flawless that he (conveniently) doesn’t realize the woman isn’t Ali until after he climaxes. When she begins rambling about using the incident in her next manipulative scheme, a struggle ensues, and Hetti kills Sam with a single blow to the forehead using the heel of a stiletto shoe. Ali learns of his death the next morning on the television news and at once realizes that her insane roommate must be responsible, prompting a lengthy melee between the two leading ladies that finally ends with a kitchen knife in Hetti’s back. The professional woman prevails this time, but minus Sam – “the best thing that ever happened to her” –
and having traumatically learned not to trust other single women.
More recently, BPD has found its way on to the small screen, in the very successful HBO series The Sopranos. The drama centres around the life of mob boss Tony Soprano, who begins seeing a psychiatrist, Jennifer Melfi, after experiencing panic attacks and depression. After a number of sessions, Melfi determines that Tony’s symptoms of mental illness, as well as his murderous tendencies and constant extramarital romps, are the result of being raised by a “borderline” mother. Tony’s mother – her cold demeanor, manipulative behaviour, and “inability to express love or experience joy” – is blamed for his criminal and philandering behaviour throughout The Sopranos’ six seasons. The fact that his father was also involved with organized crime, and the consequent violence that Tony witnessed as a child, is a footnote at best (Chase 1999).
Another interesting example of BPD in popular culture is Susanna Kaysen’s memoir Girl, Interrupted and a subsequent film adaptation of the same title. The book, published in 1993, is composed of a series of short essays, recounting Kaysen’s experience of being diagnosed with BPD and hospitalized in the 1960s, at the age of 18. The result is an astute criticism of the BPD diagnosis and its “treatment”, and a challenge to standard psychiatric discourses, largely from a feminist standpoint.
Kaysen recounts the narrow conception of appropriate conduct for the late-adolescent/twenty-something-year-old female that she encountered in 1960s, upper-middle class America – heterosexual relations being of particular concern. The simultaneous existence of the expectation for a young woman to appear attractive to and actively date members of the opposite sex, and the expectation for her not to be “too” seductive or become involved with “too many” suitors, highlights a double bind. Kaysen violates the latter “rule”, behaving “promiscuously”, manifested most contraversially in her sexual involvement with her high-school English teacher. The psychiatric faction completely overlooks the possibility that this much older man in an position of authority bore any responsibility for this scandalous relationship, instead placing all blame on sick Susanna, and using the situation as evidence of her illness.
She extends her analysis of the social expectations for women and the punishments for non-conformity in an essay devoted to the topic of the DSM criteria for BPD, especially deconstructing its emphasis on the patient’s “unstable self-image”. She argues that her own self-image was not at all unstable, but instead did not fit nicely into educational or social systems, exemplified in her desire to become a writer and her lack of interest in attending university. As well, her attempted resistance to the valued institutions of the family and school were interpreted to be symptomatic of low self-esteem, redefining rebellion against social norms as individual pathology. Kaysen includes excerpts from her official case-history in her book – under “reason for hospitalization”, it reads “Increasing patternlessness of life, promiscuous, might kill self or get pregnant” (Marshall 125). Kaysen is released two years later – curiously, upon becoming engaged. Sick becomes well when new proof of conventional femininity and conformity to cultural gender norms is demonstrated.
The film version of Girl, Interrupted (Mangold 1999), released in 1999, not only omits this detail, but turns Kaysen’s social critique into the story of a girl who strays “off track”. Despite appealing to the theme that “everyone goes a little crazy sometimes”, it fails to overcome stereotypes. The movie emphasizes Kaysen’s overt sexuality, trading the high-school English teacher for the husband of one of her parents’ friends. Like Alex Lawson in Fatal Attraction, Kaysen’s sexuality is portrayed as a dangerous and overwhelming force, and the affair is depicted as a result of a Girl, out of control. Although it does bring into question the validity of BPD, as Kaysen, played by Winona Ryder, comments that before, during, or after her hospital stay, she never understood the meaning of “BPD”. However this statement is ambiguous, as BPD’s sketchy criteria are never discussed. Her formal diagnosis aside, the film defines Kaysen as the ultimate source of her own trouble, and as entirely responsible for her own fate. She is released when she stops acting like “a lazy, self-indulgent, little girl, who is making herself crazy” (Girl, Interrupted 1999), as described by Valerie, the token African-American nurse.
b) Self-Help Literature
[BPD is] emotional hemophilia; [a borderline] lacks the clotting
mechanism needed to moderate his spurts of feeling.
Stimulate a passion, and the borderline emotionally bleeds to death.
(Self-Help Authors Kreisman and Strauss 1991)
Over the past few decades, the “Great American Novel” has been replaced by the self-help genre. Instead of waiting to be diagnosed by a clinician, a “therapeutic culture” (Rimke 2000) has fostered our desire to diagnose ourselves. Self-help literature first enabled us to self-diagnose, serving “expert” knowledge in a convenient and easily consumable package that promises to solve all of one’s woes. By implication, the individual is thus hyper-responsiblized for all of his/her troubles and distress. Although popular among men as well, women comprise the majority of self-help consumers. Two books constitute the established classics on BPD in the genre. 1991’s I Hate You, Don’t Leave Me, by Dr. Jerold Kreisman and “health writer” Hal Strauss, beckons readers by advertising on its cover the question “Am I Losing My Mind?”, followed by a list of symptoms, and the statement that ten million Americans suffer from BPD. 1998’s Stop Walking on Eggshells and its companion “workbook”, by self-proclaimed “psychotherapist” Paul T. Mason and “professional writer and public relations and marketing executive” Randi Kreger, is directed at the “friends and families” of individuals with BPD, facilitating diagnosis-by-proxy (Mason and Kreger 1998).
Stop Walking on Eggshells begins with anecdotal accounts of being in a relationship with an individual with BPD. “Joe” writes about his disillusionment with changes that occurred after his “fantasy courtship”, complete with “incredible sex”, became a marriage. His new wife had begun to turn the “meaningless” details of life into “mountains of criticism and pain”, and also accused him of unfaithfulness. However, once in a while she would turn back into her “old” self. “Larry” writes about growing up with a “borderline” mother who yelled at him when he didn’t do his chores, had unreasonable expectations of him, and was even jealous of his close relationship with the family dog, but could turn to affection when she was in the mood to receive it.
Checklists (see Rimke 2000) ensue by which one can discern whether or not their relations are “borderline”. Some features of the other two female PDs seem to emerge here, with questions including: (does this individual) “change their opinions depending on who they’re with?”, “base their beliefs on feelings rather than thoughts?”, “feel ignored when they are not the centre of attention?”, or “rush into relationships based on idealized fantasies of what they would like …them to be?” Others are so inclusive that they seem applicable to almost anyone at some point in time, such as: (does this individual) “seem unwilling to admit a mistake – or feel that everything they do is a mistake?” (my emphasis; Mason and Kreger 1998); “not realize the effect they have on others?”; “express anger inappropriately or not express anger at all”, “frequently feel spacy”, or “act competent and controlled in some situations, but extremely out of control in others?” (Ibid 13-15)
If one answers “yes” to any of the questions, they are encouraged to read on, with the promise that its contents will change one’s life for the better. Readers are discouraged from letting their kin know that they think they may have BPD to prevent unnecessary conflict – especially as BPD is less recognized and understood compared to other illnesses like “eating disorders, domestic violence, AIDS, or breast cancer…because no celebrity has admitted to having the disorder” (Mason and Kreger 1998:19). The following chapters outline the DSM criteria in depth and using more anecdotal material, subsequently offering instructions on how best to deal with these “borderline” individuals.
I Hate You, Don’t Leave Me, begins with its own ambitious claim, and one that seems very intent on creating a moral panic for exploitative purposes – that BPD is a much greater problem than anorexia, depression, or alcoholism, but one that can now be treated, in combination with books such as these that reveal the secrets of mental health professionals by explaining their knowledge in simple language that anyone may understand. Pages of the preface are also donated to a lesson on the legitimacy of “mental health” as a facet of medicine, pledging that this will become obvious during the next several decades. Recommended for borderlines as well as their families and friends, I Hate You also relies primarily on anecdotes, all about women – Jennifer, Carrie, Margaret, Lisa, and Elizabeth – to reveal “The World of the Borderline” (Kriesmann and Strauss 1991:1). A particularly paranoic passage in this first chapter, quite reminiscent of Cold War propaganda literature, warns the reader that a “borderline” could be lurking anywhere, yet undiscovered: your boss, a friend from grade school, your next-door neighbour, your son’s girlfriend – or you could be one yourself! (Kriesmann and Strauss 1991:6).
However, the book lends one later chapter to a more socially comprehensive and less psychocentric (Rimke 2000:73) hypothesis about BPD. It proposes that just as Freud’s “hysterical neurotic” was a product of repression in early twentieth-century Europe, our own times might be called the “borderline era”, and the borderline’s problems of instability in self-image and relationships might reflect “the fragmentation of stable units in contemporary society” (Kriesmann and Strauss 1991:63 ). Its discussion of the breakdown of traditional social constraints could be likened to Durkheim’s analysis of the disintegration of old forms of solidarity and his conception of anomie (Durkheim 1951, 1965), but it stops short, warning the reader that social factors are “not necessarily” directly linked to mental illness. The subsequent and final chapter returns to the prescription of individualized, psychological “treatment”, naming this as the best way to manage BPD.
c) Clinical Literature
Literature for clinicians sells the same stereotypes to therapists. More than that on any other disorder in the DSM, literature on BPD cites certain headaches for the therapist as proof of the illness. For example, in his book DSM-IV Made Easy, a widely read guide for clinicians, James Morrison’s fictional account of a typical borderline patient describes a young woman that slashes the tires of her psychiatrist’s BMW after he declines her request for a hug at the end of a session.
The most popular book for clinicians on BPD is the Skills Training Manual for Borderline Personality Disorder by Marsha Linehan, its front cover adorned with an image of a young woman’s silhouette. Published in 1993, it proposes a supposed “new alternative” to Cognitive Behavioural Therapy (CBT), the traditional format for group therapy and behaviour modification, called “Dialectical Behavioural Therapy (DBT)”. Linehan and others developed this method specifically for the treatment of individuals with BPD, although it can be, and is now widely being used, to treat a multitude of psychiatric conditions from anorexia to addiction. Upon publication, its purported fusion of concepts from both Western philosophical thought and Eastern spirituality was originally considered to be groundbreaking, and since then has become very en vogue.
Linehan gives two reasons why the therapy is called “Dialectical”: 1) it reflects the “fundamental nature of reality, and that of persuasive dialogue and relationship”, and 2) it describes “the treatment approach or strategies used by the therapist to effect change” (Linehan 1993:1). These statements, like the program that follows, have little to do with the correct definition of a “dialectic” – a logical discussion of ideas and opinions based on the process of creating a synthesis from the examination of a thesis and its antithesis. Therapy is intended to take place in small groups for five hours per week, during which handouts and worksheets (see Appendix D for examples) are distributed, discussed, and completed. Patients are also required to participate in role-playing activities with one another, as well as discussions that focus on Linehan’s material, while talking about specifically personal experiences is not allowed. Each group member must also meet with a therapist on a weekly basis. These sessions are more confessional in style, as details of the patient’s private life are permitted and encouraged topics of conversation. There are also a number of “homework assignments” that patients are expected to complete. Over the course of three or more months, four “modules” are completed – “core mindfulness skills”, “interpersonal effectiveness skills”, “emotion regulation skills”, and “distress tolerance skills”.
Although DBT and each of these modules does seem to recognize the nuanced nature of human life experience much more than older behavioural therapies, it remains that – behavioural therapy, with the sole aim of changing individuals’ behaviour, thus ignoring the social context in which it takes place. Thus, its proclaimed ties with Eastern monasticism are exposed for being quite superficial, divorced of their foundation in collectivism. The modules give examples of worldly events that may prompt a certain behavioural or emotional reaction, but only the latter are examined, and if patients in group therapy stray from talking about their personal feelings and actions, they are reminded that those of others, as well as “circumstantial details”, are not to be discussed during group sessions. The homework component involves keeping track of one’s use of the skills taught in the sessions – an example from the “distress tolerance” model being to, upon the arousal of negative emotions, force a “half-smile” over one’s lips, the theory being that “simple physical changes can alter one’s inner experience”, and often do so much faster than relying only on one’s thoughts. All techniques and exercises are intended to be gender transparent, but markedly tend to revolve around activities traditionally performed by women, such as “practicing mindfulness while washing clothes by hand, doing the dishes, or vacuuming” and “practicing interpersonal effectiveness by buying an item of clothing at a store and then going back to return it”. Lastly, the “emotional regulation skills” section’s instructions for dealing with anger seem peculiarly unprogressive, instructing one to “gently AVOID person you are angry with” and “do something NICE [for the said person]”.
The program’s stated goal in helping individuals, young women in particular, to improve their “self-esteem” – a concept created by the psy-establishment that has risen to great prominence, pervading our culture as it has come to be seen as a crucially important quality for the individual to possess (Ward 1996) – in order to decrease painful states of mind and increase one’s enjoyment of life seems quite authentic, but it fails to live up to its name as a revolutionary tool in the field of psychiatry and mental health, as it locates pathology strictly in one’s “disordered” mind and “personality”, and thus preaches the same old mantra – that when one experiences mental anguish, angst, apathy, anger, et cetera, the solution must be to make some kind of adjustment to oneself – to one’s thoughts, to one’s feelings, to one’s behaviour – a principle that fundamentally fails in its refusal to recognize any of all that exists beyond the individual, and that is much bigger than the individual – the values, the institutions, the ideologies, the structures of power – in this discussion specifically, gender relations – facets of the social world that create the human experience, and of which the individual is merely a receiver, no matter how finely tuned. So we speak less and less often about making any adjustments outside of ourselves, as we ask more and more often, and instead, “What is wrong with me?” The discontent that once fuelled protest now fuels Prozac sales, and a whole industry created to capitalize on our misery, selling us distraction.
d) Internet Websites
Finally, with the rise of the Internet, psychologists and other self-help gurus are able to reach people beyond the bookstore, in their homes via websites that spread their gospel of self-diagnosis and self-improvement, and their ensuing promise of a better life. Extensive information about all personality disorders is available online: lists of symptoms and signs to recognize in oneself or others, various hypotheses about their causes, treatment options including psychotherapy and medication – it is common for pharmaceutical companies to advertise antidepressants and other psychotropic drugs on these sites, quizzes that one may take in order to determine which personality disorders he or she may have measured by degree of severity, and recommendations for local support groups and clinicians.
However, again BPD receives the most attention by far (see Appendix E for detailed quantitative data). It is difficult to find sites dedicated completely to any of the other disorders, but there are many exclusively on the topic of BPD. Upon performing a search for the phrase “personality disorders help” using the Google search engine, of the first thirty results, fourteen are pages on personality disorders in general, an equal number (fourteen) are pages on BPD, one page is on the “Cluster B” personality disorders, and only one is on an other personality disorder, Narcissistic Personality Disorder – one diagnosed primarily in men. There could be several reasons for this, an obvious one being that BPD has become the most frequently diagnosed personality disorder since its first appearance in the DSM-III. The attention paid to it in media of popular culture has also sparked interest as to what the term “borderline” really means. Another possibility is that women spend more time researching psychological disorders on the Internet, which is likely the case if statistics on the consumption of self-help books can be inferred to websites, thus creating a higher demand for information on disorders that primarily affect women. Women are also more likely to come to the conclusion that the experience of “dysphoria” is evidence that they may be suffering from a mental illness rather than situational distress, the reasons for which could be the topic of another paper, one important one being pharmaceutical advertisements – while the most common medications advertised to men are for “erectile dysfunction”, most ads directed at women are for mood-enhancers like SSRI antidepressants. (Perhaps there is a relationship here, as the former class of drugs are more useful if women are in a good mood).
The number (seven) of this sample of thirty websites that are hosted by well-established medical organizations like the Mayo Clinic, who deal primarily with physical illnesses and who have earned public respect for their knowledge of general medicine, speaks to the legitimation of psychiatry and its most unscientific disorders by the medical establishment. The greatest number of sites (thirteen) are hosted by psy-organizations composed of many scholars of psychology and psychiatry. Two Wikipedia articles come up, which is quite standard for any search on the Internet, as it has become one of the most popular and frequented websites for information on any topic. Four sites are hosted by lay individuals, “psy-entrepreneurs” with no apparent formal knowledge of the psy-ences, who have taken it upon themselves to give advice to others on issues regarding the personality disorders. Finally, four sites are hosted by “self-help experts” – individuals who also lack credentials in the fields of psychology or psychiatry, but have been granted respect and authority by the public because they have published self-help books, sometimes leading to other exposure, for example on television. Their primary motivation seems to be capitalizing on the success of this genre, and the tendency of individuals in neo-liberal society to search for any source that will offer advice on the improvement of the self.
The largest and most frequented site on BPD is “www.BPDCentral.com” (Google 2009), hosted by Randi Kreger (Kreger 2005), the previously mentioned co-author of Stop Walking on Eggshells. Although it is recommended to individuals diagnosed with BPD, like the book, the site seems more preoccupied with the people “affected” by these individuals that have BPD, justified in its “FAQ” section, where the claim is made that while “over six million people in the United States have a BPD disorder…these people affect the lives of at least thirty million others.” One section is devoted to advice to follow when divorcing someone with BPD, and links to other sites on this topic. Of these links, eighteen are headed as “for men”, two are “for men and women”, and three are “for children”. Much space is also devoted to the topic of how to coerce individuals who are exhibiting the signs of BPD to seek and accept medical treatment. The argument that BPD may afflict children, which contradicts the current edition of the DSM, is also propagated. Signs that an adolescent may have the disorder include “confusion about one’s identity and values”, “feeling empty”, and even getting “piercings”, which is included as a form of “self-harm”. Upon publication, the DSM-V will reveal if childhood BPD is formally validated as a diagnostic category, which would demonstrate another instance of the looping effect, in this case initiated by the self-help industry (Rimke 2000).
One final favourite subject, coming up time and again while navigating BPDCentral, is that of “splitting” – the tendency of the “borderline” individual to view other people binarily, as entirely good or entirely “evil”, and cycling back and forth between the two. The cultural meaning of such thinking, which of course is not discussed, is particularly intriguing. We live in a world dominated by binary ideology, where members of society are typified in exactly this way: as either one thing or another, as either “good” or “evil” – this particular example being founded upon Christian theology – and where the world’s most powerful politicians’ rhetoric is obsessed with these dichotomies, and foreign relations are viewed through a lens of “us versus them” philosophy. One must ask why this pattern of thinking and behaviour is considered pathological when expressed by individuals with little power, here with the example of women, but is not when exercised by powerful individuals and institutions.
The current public obsession with all things “psy” (Rimke 2000, Rose 1986) is responsible for mass distraction from these institutions and their representatives, as the psy-industry propagates the idea that dysphoria results from individual flaws and biological deficiencies, and can thus be remedied by self-improvement, whether it be through following the doctrine of a particular self-help book, joining a Dialectical Behavioural Therapy group, or seeing a psychiatrist and taking prescribed psychopharmacological drugs. A woman diagnosed with BPD, HPD, or DPD will likely be encouraged to pursue all of these avenues. Under the “expert gaze”, her fatal flaw is “abnormality”, for as previously mentioned, the personality disorders are defined as “pathological manifestations of normal personality traits” (Trull and Widiger 2003:149). The desire to be “normal” is what feeds the psy-establishment, but the emergence of this particular desire is a relatively recent phenomenon. The next section will explore the creation of normalcy, and its consequences.
6. Dangerous Women in Neo-Liberal Society: Psychiatric Power and The Shrinking
Spectrum of Normalcy
and somewhere in the 80s between the oat bran and the ozone
she started to figure out things like why
one eye pointed upwards looking for the holes in the sky
one eye on the little flashing red light
a picasso face twisted and listing down the canvas
of the end of an endless night
(DiFranco, Ani. “Tamburitza Lingua”)
The field of psychiatry, and its bible the DSM, have been granted the power and privilege to define what “normal” human – and female – conduct is, and what other behaviours deviate into the realm of the “abnormal”. Smith (1990) considers the consequences of this system, arguing that socially organized, objectified forms of knowledge, such as those established by psychiatry and contained in its compendium of “mental illnesses” are central to the perpetuation of power relations in contemporary patriarchal societies. Psychiatry is so powerful that upon its mere use of the word “disorder”, all investigations into the same phenomenon by other disciplines are trivialized, discredited, or halted, obstructing the possibility for deeper understanding, and effectively limiting thought and shaping practice. It has used its power to pathologize behaviour that violates social norms, including attempts to defy gender stereotypes, as well as expressions of frustration with, and attempts to resist patriarchal subordination. Explaining “difficult” or “deviant” behaviour with the medical model, which blames individual pathology – in this case the individual’s “disturbed personality” – detracts all attention from the social context of gendered power relations which arguably produces such behaviour, a hypothesis that will be examined in the final chapter.
Each new edition of the DSM defines an increasing number of mental disorders, both representing and enforcing what may be called a “shrinking spectrum of normalcy” that has come to pervade our culture, and infringe upon all spheres of human life. The rapid extension of the application of this model upon children and childhood over the past two decades demonstrates the extent of its authoritative accomplishment – another issue that exemplifies this “spectrum” and demands critical inquiry. While consumerism offers us the illusion of choice and the ability to “define” oneself uniquely, society’s definition of acceptable and unacceptable behaviour has, and continues to, become more and more restricted. Efficiency demands uniformity, and as we strive to be “normal”, we voluntarily McDonaldize our lives and selves.
While social standards for behaviour, that for females as well as males, have existed across societies geographically and temporally, our obsession with being “normal” is a fairly recent phenomenon, a trend that has been unearthed and analyzed by scholars including Rimke, who uses the term “normopathy” to challenge the idea that it is “normal” to desire, above all else, to be “normal” (Rimke 2000). The idea of being “normal” only emerged in the second half of the nineteenth century, upon the first major collection of demographic data from the French population, and statistician Quetelet’s subsequent definition of the l’homme moyenne – the “average man”, a spectre against which one may measure oneself to determine his/her normalcy (Bierne 1987). Whereas psychiatry was originally concerned with public hygiene and the protection of society from illness, upon the emergence of the “abnormal” individual, which coincided with the vast expansion of disciplinary techniques and technologies, it quickly laid claim to the domain of “abnormality”.
Prisons, schools, asylums, factories, and other societal institutions were increasingly concerned with efficiency, thus such techniques as the strict regimentation of time and panoptic supervision were adopted. These features required obedient subjects whose bodies could, with the proper “training”, be successfully reconstituted as unquestioningly docile; thus, incompliant individuals were soon labeled “abnormal”, based on the sole factor of their inability to conform to institutional demands (Foucault 1977). An adverse reaction to a particular environment was now located in individual pathology, described as abnormality, which could be “treated” either by subjecting one to even more rigid conditions, or through psychiatric intervention. The rise of psychiatry was thus largely founded upon the possibility of its use as a tool for institutional efficiency, while it purported its goal to be the improvement of the lives of individuals. As the twentieth century progressed, the importance of normalcy continued to advance, permeating all spheres of discourse, and becoming a quality desired by the individual, initiating the self-governance described by Foucault in his concept of Governmentality. Psychiatry’s monopoly on the treatment of abnormality was solidified as it became a “science”, and upon the advent of the cult of self-improvement that accompanied the neo-liberal reforms of the 1980s, the scope of its influence grew to encompass the mundane, everyday lives of individuals. Indeed, it is incredibly difficult to avoid the offerings of the psy-complex now, as incessant advertisements beckon us to take psychopharmaceuticals between segments of “Dr. Phil”.
The “personality quiz”, a longtime feature in women’s magazines, is a quick and easy way to determine if one’s habits, lifestyle, and relationships measure up to standards of normalcy, or could use some adjustment, or perhaps even some “treatment”. The Internet has taken these quizzes to the next level, and everyone from Pfizer, to self-help authors, to lay-people have developed series of questions that one may utilize to self-diagnose. One may see this as a particularly extreme manifestation of Governmentality, as individuals voluntarily evaluate their lives and voluntarily make changes to their behaviour.
The trend towards the medicalization of more and more aspects of everyday life and the narrowing of the qualifications required to achieve at being “normal” continues to expand. The DSM-V, when published in 2012, will name a host of newly “discovered” disorders alongside the redefinition of those already established in earlier editions, extending psychiatry’s influence and intrusion upon the lives of more and more individuals, and colouring more and more of the variations between individuals with the brush of insanity. Researchers have proposed a new “continuum” model for the DSM-V that would once again multiply exponentially the number of individuals at risk of being branded with some form of personality disorder. In this new diagnostic prototype, the clinician would be able to make a “dimensional diagnosis” using a “simple five-point scale”: “1) description does not apply; 2) patient has some features of this disorder; 3) patient has significant features of this disorder; 4) patient has disorder, diagnosis applies; and 5) patient exemplifies this disorder, prototypical case”. This proposed model was derived specifically from difficulties encountered when diagnosing BPD (Bradley et al. 2007:188-189). If adopted, diagnoses and justification for treatment will no longer be limited to those who exhibit “five or more” of the symptoms listed under the heading of a particular personality disorder.
7. Conceptual Quagmire: The Issue of Abuse
Daddy, daddy, you bastard, I’m through.
As the cause of the three specific “mental disorders” examined in this paper – and indeed that of all “mental disorders” – is located in the individual’s “disordered” mind, social conditions are ignored. Throughout history, positive social change has been spurred by individual and collective discontent, serving as motivation to improve the social world. By assigning discontent to the realm of the abnormal, and locating its source in individual pathology, its potential to inspire action is crushed. In addition, it isolates individuals from one another and stifles dialogue, as one’s “troubles” are transformed into a reason for shame, and something that must be remedied on one’s own, with the help of the “expertise” offered by the psy-ences.
Returning again to the specific case of females, features of society that perpetuate the oppression of women as a whole remain unexamined, as individual women are assigned blame for the inability to achieve satisfaction. By deviantizing and pathologizing individual interpretations of, and reactions to social conditions, social mechanisms of female subordination are shadowed, enabling them to prevail indefinitely.
A major defining characteristic of all three PDs discussed here, especially central to the BPD diagnosis, is “instability” – “[She] is said to lack a stable, coherent self” (Wirth-Cauchon 2001:80). Our perversely judgmental society – its judgment especially severe upon women, their bodies, and their behaviour – makes it a challenge for any female to maintain a stable, confident self-image. Every moment of the day advertising bombards women with a barrage of images of other women with perfect bodies, faces, and domiciles, without the disclaimer that they are not realistic, but an unattainable fantasy.
Upon puberty and adolescence girls learn that they are sexualized beings, and the constant objects of male evaluation and attention (Becker 1997:159). They learn that this will always hold true, regardless of what other accomplishments they may achieve – being considered physically attractive or unattractive will still permeate all aspects of life. Women who are rightfully sensitive to this environment, finding it difficult to be consistently self-assured while inhabiting a body that doesn’t match the airbrushed images screaming from the pages of magazines, are pathologized – labeled sick for their reaction to this disparaging landscape. Any examination of the “health” of such a society is muted. The double-bind arises once more, as one criteria for HPD is “preoccupation with physical attractiveness”. It seems more than reasonable to ask then, if all of the women on the pages of Vogue, the ladies of Sex and the City, and any female strutting the streets in three hundred dollar shoes, is suffering from HPD, and would benefit from a little therapy, a little self-help, or a little Prozac.
Psychoanalyst Ross, reappraising Freud’s sessions with “Dora”, his most famous female patient, concludes that this most notorious case of “hysteria” was actually a case of BPD, emphasizing Dora’s inability to speak of her private inner life, and concentration instead on the actions and opinions of people around her (Wirth-Cauchon 2001:180). Through elementary socialization, society forces women to look to others for approval and to use this as the basis of their perceived success in life; it seems they must do so quietly in order to avoid the risk of being labeled “mentally unstable”, and given a diagnosis of DPD or BPD.
A focus on physical attractiveness and its use as an indicator of proficiency even pervades a woman’s experience within psychiatry. In research for her project on BPD, Wirth-Cauchon (2001:92), examined the psychiatric records of patients with a diagnosis of BPD, observing the frequent occurrence of detailed descriptions of the physical appearance of female borderline patients – aesthetic eccentricities or dishevelment were used as evidence of BPD. Many descriptions also include reference to the patient’s overt sexuality, depicted again as a sign of “illness”. Such attention to physical appearance is rarely found in doctors’ notes on male patients.
Several feminist scholars (Becker 1997, Brown and Ballou 2002, Russell 1987) argue that BPD not only pathologizes over- and under-conforming to female stereotypes, but also pathologizes behaviour that constitutes a “normal” response to oppression. “The Stress Paradigm” is often cited, asserting that in lack of social supports and direction, the individual adopts coping mechanisms symptomatic of mental illnesses to deal with severe stressors resulting from trauma. The DSM-IV defines “trauma” as “[exposure to] an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others” (APA 1994 as cited in Becker 2000:425). Following the DSM’s own definition, trauma is inevitably experienced by all women – taking on a variety of forms from the subtle but constant objectification described by the Foucauldian feminist conception of the “male gaze” (Owens 1985:71), to the “stolen glance”, to the more violent and “socially unacceptable” but extremely common act of rape – living in a society where male on female abuse is congratulated more often than it is punished. These PDs can thus be a response to two distinct instances of abuse: 1) The universal experience of abuse women endure by living in current society, or 2) Individual cases of physical, sexual, emotional, or other abuse.
In the first case, universal trauma and psychological abuse is experienced by all women, a function of their subordinate status in a patriarchal society. Certain personality traits consistently arise among members of subordinate groups, especially when rank is assigned at birth, as is the case with regard to gender (Collins 1998:98). These traits that emerge as survival skills for oppressed individuals curiously match the previously discussed “appropriate female” traits, as well as traits exhibited by individuals with HPD, DPD, and BPD, as outlined in the DSM. Their formation follows a logical process. Upon attempting to express concerns and solve problems, subordinated individuals experience the dismissal of their ideas as not credible or important. If the individual attempts to voice frustration about being ignored, s/he only meets more abatement. As a social being, the subordinate quickly adopts behaviours that will please resource-rich dominators, becoming passive and losing touch with one’s true interests – one can see how this might lead to “difficulty initiating projects or doing things on one’s own” (APA 1994), being highly “suggestible” (ibid), or experiencing “chronic feelings of emptiness”, criteria for DPD, HPD, and BPD, respectively. At the same time the subordinate internalizes messages that s/he is less important and less valued than dominators. Occasional emotional outbursts – perhaps “borderline rage” or histrionic “self-dramatization, theatricality, and exaggerated expression of emotion” – make up for the lack of any constructive outlet for dissatisfaction (Collins 1998:100). Subordinate individuals display depression, anxiety, increased emotionality, dependency, worrying, difficulty experiencing disagreement for fear of rejection, and going to extremes to please others – all symptoms of at least one of the PDs discussed here.
In regard to the second category of specific, personal cases of abuse, the correlation between being diagnosed with a PD and having experienced sexual, physical, or emotional abuse is undeniably significant. The strongest correlative relationship exists between the BPD diagnosis and the previous experience of sexual abuse – statistics from a 1989 sample of BPD patients showed that 81% of them had experienced childhood physical or sexual abuse (Herman et al. 1999 as cited in Bradley et al. 2007). The majority of individuals diagnosed with BPD have at some time in their lives experienced sexual abuse. It is cruelly ironic that the expression of anger – perhaps of the so-called “intense” variety – by women who have been victims of sexual abuse is used as evidence of individual pathology, rather than a “healthy” or “normal” response to the severe trauma associated with this most intimate of violations. Linehan’s worksheets from the “Distress Tolerance” module of her program (see Appendix D) are disturbing in their seeming promotion of the complete elimination of the experience of anger, even that directed at the “person you despise or hate most”, who, following the high rates of sexual abuse, are probably very often one of the persons who has committed an act of abuse against the female patient.
Researchers point to the fact that, from Freudian psychoanalytic theory to the more recent “discovery” of “False Memory Syndrome”, sexual abuse has a deep history of denial, distortion, and blaming the victim, which continues to dominate society’s and psychiatry’s attitudes towards its victims. Shaw and Proctor, among others, argue that BPD is a “powerful new manifestation of this tendency to deny the extent and impact of childhood sexual abuse” (Shaw and Proctor 2005:486). BPD, and the other PDs, regard the “symptoms” detailed in their criteria to be in and of themselves indicative of disorder, without consideration of the individual’s history, much less the history of subordination felt by all women. Of course dealing with these latter factors is far more time-consuming, costly, and complicated than checking of items on the DSM’s lists and making a cookie-cutter diagnosis, violating the neo-liberal principle of efficiency. Considering that the average length of a maintenance appointment with a psychiatrist is twenty minutes at best, doing so would detract from the efficiency, and thus the profits, of the mental health industry. Thus, women are individualized and pathologized for their responses to oppression, while the context of oppression remains unexamined.
In Western society today, the belief that the oppression of women has ended is a common one, promoted in popular media such as television “newstainment” stations like CNN, FoxNEWS, and MSNBC, that will no doubt continue to cite the election of Hillary Clinton as a presidential candidate as evidence that the goals of feminism have been realized, men and women are truly equal now, and the movement(s) no longer have a purpose. Thus, the case of the deviantization and regulation of women serves as a particularly salient example of the largely unnoticed and unexamined, but incredibly vast power and authority of psychiatry and the larger psy-establishment, so entrenched that although it is one of the chief institutions of social regulation, our society and culture do not view it as an agent of regulation, but assume it is e ntirely benevolent, unquestioningly accept its sketchy claims as factual truths, and rely on it to provide the individual with the keys to contentment and success at life.
Meanwhile, the true fact, supported by a huge body of research, is that psychiatry is responsible for continuing to punish women for disobeying the same sexist, patriarchal mores that that once justified witch-burnings in the name of “morality”, then defined by the institution of religion. The specific cases of HPD, DPD, and BPD are particularly vivid in their resemblance to the earlier “female” mental diseases like hysteria and moral insanity, but they only skim the surface of the damage done to females by all things psy. As they are the primary targets of “depression” diagnoses, they form the majority of consumers of recklessly prescribed, unresearched, or scientifically disproved of having any statistically significant benefit “mystery pills”, sold by advertisements that offer the promise of happiness never before experienced. The burgeoning offshoot industry of self-help, capitalizes shamelessly on the human desire to experience pleasure and the failure of society to provide the basic material conditions and personal liberties that would eliminate the need for the genre.
The “solutions” to distress it offered by the psy-establishment locate the source of unpleasant feelings in individual pathology, a manifestation and facilitator of neo-liberal values that divert attention and energy from our social conditions, by discounting and obscuring their role in our emotional, physical, and spiritual satisfaction or disillusionment. Following the tenets of Foucault’s theories of discipline and Governmentality, our spontaneous compliance with the institutional regulations imposed by psychiatry is a sign that citizens have been rendered so docile that the need for government, originally created to fulfill the “need” to regulate a sovereign nation-state and its occupants, is quickly being eliminated, not because of revolution or upheaval, but because of the defeat of the individual. So successful were the institutional technologies of discipline introduced a century and a half ago (Foucault 1977a), that over a few generations subjects no longer needed to be told what to do, as they are voluntarily obedient to non-governmental regulatory agencies. Modern citizens are not longer subject to the masters of the old world, but are directed by institutions they created themselves, for their own well being – yet they are not free, but rather are more regulated than ever, and in a final cruel irony, the source of their predicament does lie within them, one may even make the leap that their fate was determined at birth.
This tempting illusion, at once removing us of responsibility for our circumstances, but also hyper-responsibilizing the self by locating discontent in the body, is doubly deceitful. The psy-ences will continue to be authoritative and powerful, as they offer a glimmer of false hope that will surely allow us to remain on the same path.
The phenomenon I have called The Shrinking Spectrum of Normalcy may be seen as stark evidence of the path we are on and the increasing speed at which we are traveling. The institution we blindly trust to take care of us, fix us when we are sad, and help us achieve our distinctly unique individual potential is systematically decreasing the range of acceptable conduct, lifestyle choices, and medicalizing other idiosyncrasies that were valued not long ago. Their banishment to the dungeons of abnormality serves to promote an increasingly narrow model of the ideal citizen – efficient, productive, compliant, disciplined, with any existential crises blurred by psychopharmaceuticals.
Already marginalized, vulnerable groups are favourite targets. In this paper the case of the psychiatrization and social regulation of traditionally deviant women, as well as women newly included in the category after the “discovery” of DPD in 1980, was traced to similar historical patterns of female oppression using the genealogical method, and both historical and current discourse was analyzed to reveal the extent of the pervasive nature of female stereotypes based on the personality disorders, and the propagation of these caricatures by the media of popular culture. Children are the latest victims of psychiatric regulation, and the 40-fold increase in the number of children diagnosed with the condition of “Early Onset Bipolar Disorder” over the past ten years is alarming. The consequences for children subjected to the Shrinking Spectrum of Normalcy have not yet been examined, and will be the basis of my forthcoming M.A. Thesis.
DSM-IV Criteria for Borderline Personality Disorder
“a pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts A DSM diagnosis of BPD requires any five out of nine listed criteria to be present for a significant period of time”:
1) Frantic efforts to avoid real or imagined abandonment. [Not including suicidal or self-mutilating behavior covered in Criterion 5]
4) Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving). [Again, not including suicidal or self-mutilating behavior covered in Criterion 5]
7) Chronic feelings of emptiness, worthlessness.
8) Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
DSM-IV Criteria for Histrionic Personality Disorder
“a pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following”:
1) Is uncomfortable in situations in which he or she is not the center of attention
2) Interaction with others is often characterized by inappropriate sexually seductive or provocative behaviour
3) Displays rapidly shifting and shallow expression of emotions
4) Consistently uses physical appearance to draw attention to self
5) Has a style of speech that is excessively impressionistic and lacking in detail
6) Shows self-dramatization, theatricality, and exaggerated expression of emotion
7) Is suggestible, i.e., easily influenced by others or circumstances
8) Considers relationships to be more intimate than they actually are.
DSM-IV Criteria for Dependent Personality Disorder
“a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following”:
1) Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
2) Needs others to assume responsibility for most major areas of his or her life
3) Has difficulty expressing disagreement with others because of fear of loss of support or approval (this does not include realistic fears of retribution)
4) Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)
5) Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
6) Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
7) Urgently seeks another relationship as a source of care and support when a close relationship ends
8) Is unrealistically preoccupied with fears of being left to take care of himself or herself
A Sample of “Handout” Literature and Worksheets, and “Homework Sheets” from Linehan’s Skills Training Manual for Treating Borderline Personality Disorder, with examples from all four of the “modules” covered in the course of therapy: “Core Mindfulness”, “Distress Tolerance”, “Emotion Regulation”, and “Interpersonal Effectiveness” (Linehan 1993)
Appendix E: Google Search Results and Statistics
Search term: “personality disorders help”
First Thirty Results: 1. “Personality Disorders” www.mentalhelp.net/poc/center_index.php?id=8
2. “Personality Disorders, Mental Health Disorders, Merck Manual
3. Personality Disorder: Wikipedia, The Free Encyclopedia
4. BBC Health – Conditions – Personality Disorders
6. Personality Disorder Test
8. Personality Disorders: Symptoms – MayoClinic.com
9. Mind > Information > Booklets by Series
10. FocusAS: Personality Disorders
11. Borderline Personality Disorder Treatment: PsychCentral
12. Personality Disorders @ Suite101.com
13. Borderline Personality Disorder – Support Group for Families
14. Borderline Personality Disorder: Wikipedia, the Free Encyclopedia
15. BPD: Causes, Symptoms, Treatment
16. Borderline Personality Disorder Treatment
17. Borderline Personality Disorder
18. Narcissistic Personality Disorder
19. NIMH – Borderline Personality Disorder
20. Personality Disorders: Advice, Books, Info, and Help
21. Borderline Personality Disorder Treatment
22. Mind > Information > Booklets by Series
23. Self-Help for Managing the Symptoms of Borderline Personality Disorder
25. SANE.org.uk – Personality Disorders: www.sane.org.uk/AboutMentalIllness/PersonalityDisorders
26. Personality Disorders: Cluster B
27. Borderline Personality Disorder Symptoms
28. Borderline Personality Disorder Fact Sheet
29. Personality Disorders: Etiology, Symptoms, Treatment, and Prognosis
30. Personality Disorder Programme Homepage
Sites by Topic
Sites Devoted to Personality Disorders in General: 14
Sites Devoted to Borderline Personality Disorder: 14
Sites Devoted to “Cluster B” Personality Disorders: 1
Sites Devoted Other Personality Disorders: 1 (Narcissistic)
Site Hosts by Type
General Medicine (e.g. “Mayo Clinic”): 7
General Psychology, Psy-“Experts”: (e.g. “All Psych”): 13
Self-Help “Experts” (no formal background in the psy-ences,e.g. BPDCentral): 4
Independent “Lay Persons”(e.g. “4degreez”): 4
American Psychiatric Association (APA). 1952, 1968, 1980, 1983, 1994. The
Diagnostic and Statistical Manual of Mental Disorders, editions 1-4 and 3-Revised (DSM-I, DSM-II, DSM-III, DSM-III-R, DSM-IV). Arlington, VA: APA.
Amos, Tori. “Liquid Diamonds.” (Musical Composition)
Becker, D. 1997. Through the Looking Glass: Women and Borderline Personality
Disorder. Boulder CO: Westview Press.
Becker, D. 2000. “When She Was Bad: Borderline Personality Disorder in a
Posttraumatic Age.” American Journal of Orthopsychiatry, 70, 4, 422-432.
Bierne, P. 1987. “Adolphe Quetelet and the Origins of Positivist Criminology.”
American Journal of Sociology. 92, 5, 1140-1169.
Bjorklund, P. 2006. “No Man’s Land: Gender Bias and Social Constructivism in the
Diagnosis of Borderline Personality Disorder.” Issues in Mental Health Nursing, 27, 3-23.
Blum, L. and Stracuzzi, N. 2004. “Gender in the Prozac Nation: Popular Discourse and
Productive Femininity” Gender & Society, 18, 269 – 286.
Blagov, P., Fowler, K. and Lilienfield, S. 2007. “Histrionic Personality Disorder.” in W.
O’Donohue, K. Fowler, and S. Lilienfield (eds.) Personality Disorders: Towards
The DSM-V. Los Angeles: Sage. 203-232.
Bornstein, R. 2007. “Dependent Personality Disorder.” in W.O’Donohue, K. Fowler,
and S. Lilienfield (eds.) Personality Disorders: TowardsThe DSM-V. Los Angeles: Sage. 307-324.
Bradley, R., Zittel Conklin, C., and Westen, D. 2007. “Borderline Personality Disorder.”
in W.O’Donohue, K. Fowler, and S. Lilienfield (eds.) Personality Disorders:
TowardsThe DSM-V. Los Angeles: Sage. 167-201.
Brown G., and Anderson, B. 1991. “Psychiatric Morbidity in Adult Inpatients with Childhood Histories of Sexual and Physical Abuse“. American Journal of Psychiatry. 148, 1, 55–61.
Brown, L. and Ballou, M. 2002. Rethinking Mental Health and Disorder: Feminist
Perspectives. New York: The Guilford Press.
Busfield, J. and Campling, J. 1996. Men, Women, and Madness: Understanding Gender
and Mental Disorder. New York: NYU Press.
Caplan, B. 2006. “The Economics of Szasz.” Rationality and Society, 18, 3, 333-366.
Castel, Robert. 1991. “From Dangerousness to Risk” G. Burchell et al (Eds). The
Foucault Effect: Studies In Governmentality. London: Harvester Wheatsheaf.
Cermele, J., Daniels, S., and Anderson, K. 2001. “Defining Normal: Constructions of
Race and Gender in the DSM-IV Casebook.” Feminism and Psychology, 11, 2, 229-247.
Chamberlin, J. 1975. “Women’s Oppression and Psychiatric Oppression.” Smith, D.
and David, J (eds.). Women Look at Psychiatry. Vancouver: Press Gang Publishers.
Chase, D. (Creator) 1999, February 14. “Pax Soprana” The Sopranos. Bravo Canada.
Chesler, P. 2005. Women and Madness. New York: Four Walls Eight Windows.
Chodoff, Paul. 1982. “Hysteria and Women.” The American Journal of Psychiatry,
Chunn, D. and Menzies, R. 1990. “Gender, Madness and Crime: The Reproduction of
Patriarchal and Class Relations in a Psychiatric Court Clinic.” Critical Criminology. 1, 2, 33-54.
Collins, L. 1998. “Illustrating Feminist Theory: Power and Psychopathology.”
Psychology of Women Quarterly, 22, 97-112.
Conrad, P. and Schneider, J. 1980. Deviance and Medicalization: From Badness to
Sickness. St. Louis: The C.V. Mosby Company.
Cross, S.E., Bacon, P.L., and Morris, M.L. 2000. “The Relational-Interdependent Self-
Construal and Relationships.” Journal of Personality and Social Psychology.
Derrida, J. 1978. “‘Genesis and Structure’ and Phenomenology” from Writing and
Difference Alan Bass (trans). London & New York: Routledge.
Didi-Huberman, G. 2004. Invention of Hysteria: Charcot and the Photographic
Iconography of the Salpetriere. Massachusetts: The MIT Press.
DiFranco, Ani. “Tamburitza Lingua” (Musical Composition)
Durkheim, E. 1951. “Anomic Suicide.” Suicide: A Study in Sociology. George A.
Simpson (trans.) New York: Free Press.
Durkheim, E. 1965. “The Human Meaning of Religion.” The Elementary Forms of
Religious Life. Joseph Ward Swain (trans.) New York: Free Press.
Dworkin, Ronald. 2001. “The Medicalization of Unhappiness.” The Public Interest, 144,
Elden, S. 2006. “Discipline, Health, and Madness: Foucault’s Le Pouvoir
Psychiatrique.” History of the Human Sciences. 19, 1, 39-66.
Foucault, M. 1965. Madness and Civilization. Howard, R. (trans.) New York: Random
Foucault, M. 1977a. Discipline and Punish: The Birth of the Prison. Alan Sheridan
(trans.) New York: Vintage Books
Foucault, M. 1977b. “Nietzsche, Genealogy, History.” in D.F. Bouchard (ed.)
Language, Counter-Memory, Practice: Selected Essays and Interviews. Ithaca:
Cornell University Press. 139-164.
Foucault, M. 1978. “Governmentality.” in G. Burchell et al. (ed.) The Foucault Effect:
Studies in Governmentality. Chicago: University of Chicago Press. 87-104.
Foucault, M. 2006. History of Madness. New York: Routledge.
Freud, S. and Breuer, J. 1895/2000. “Studies on Hysteria.” in J. Strachey (ed.) The
Standard Edition of the Complete Psychological Works of Sigmund Freud:
Volume Two. London: Hogarth.
Freud, S. 1905. “Fragment of an Analysis of a Case of Hysteria (‘Dora’)” in A. Richards
(ed.) Sigmund Freud: Volume Eight, Case Histories I. New York: Penguin.
Goffman E. 1961. Asylums: Essays on the Social Situation of Mental patients and Other
Inmates. Harmondsworth: Penguin.
Google. 2009. Search results for phrase “personality disorders help”; Last accessed
April 20, 2009. go to:
Gove, W. and Tudor, J. 1977. “Sex Differences in Mental Illness: A Comment on
Dohrenwend and Dohrenwend.” American Journal of Sociology. 82, 6, 1327-1336.
Grob, G. 1991. “Origins of DSM-I: A Study in Appearance and Reality” American
Journal of Psychiatry. 148, 4, 421–31.
Hacking, I. 1999. “Madness: Biological or Constructed?” in The Social Construction of
What? Cambridge: Harvard University Press. 100-124.
Haines, Emily. “Doctor Blind” (Musical Composition)
Healy, D. 1997. The Antidepressant Era. Cambridge: Harvard University Press.
Hicks, J. 2005. Fifty Signs of Mental Illness. New Haven: Yale University Press.
Jimenez, M. 1997. “Gender and Psychiatry: Psychiatric Conceptions of Mental
Disorders in Women, 1960-1994.” Affilia, 12, 2, 154-175.
Kaplan, M. 1983. “A Woman’s View of the DSM-III.” American Psychologist, 38,
Kimball, M. 1975. “Women, Sex-Role Stereotypes, and Mental Health: Catch 22.”
Smith, D. and David, J (eds.). Women Look at Psychiatry. Vancouver: Press Gang Publishers.
Kirk, S. and Kutchins, H. 1992. The Selling of DSM: The Rhetoric of Science in
Psychiatry. New York: Aldine De Gruyter.
Kluft, Richard P. 1990. Incest-Related Syndromes of Adult Psychopathology.
Kreger, R. 2005. BPDCentral. Go to: http://www.bpdcentral.com/index.php
Kreisman, J. and Straus, H. 1991. I Hate You, Don’t Leave Me: Understanding the
Borderline Personality. New York: Harpercollins.
Kupers, T. 1999. Prison Madness: The Mental Health Crisis Behind Bars and What We
Must Do About it.” San Fransisco: Jossey-Bass Inc.
Kutchins, H. and Kirk, S. 1998. Making Us Crazy: DSM: The Psychiatric Bible and the
Creation of Mental Disorders. New York: Free Press.
Larsen, R. and Buss, D. 2005. Personality Psychology. New York: McGraw Hill.
Lerman, H. 1996. Pigeonholing Women’s Misery. New York: Basic Books.
Linehan, M. 1993. Skills Training Manual for Treating Borderline Personality
Disorder. New York: The Guilford Press.
Lyne, A. (dir.) 1987. Fatal Attraction. Perf: Michael Douglas, Glenn Close, Ann
Archer. Paramount Pictures.
Maines, Rachel P. 1998. The Technology of Orgasm: “Hysteria”, The Vibrator, and
Women’s Sexual Satisfaction. Baltimore: The Johns Hopkins University Press.
Mangold, J. (dir.) 1999. Girl, Interrupted. Perf: Winona Ryder, Angelina Jolie,
Clea Duvall, Brittany Murphy. 3 Art Entertainment.
Marshall, E. 2006. “Borderline Girlhoods: Mental Illness, Adolescence, and Femininity
in Girl, Interrupted.” The Lion and the Unicorn, 30, 117-133.
Martin, B. 1982. “Feminism, Criticism, and Foucault.” New German Critique. 27, 3-
Mason, P. and Kreger, R. 1998. Stop Walking on Eggshells: Taking Your Life Back
When Someone You Care About Has Borderline Personality Disorder. Oakland: New Harbinger Publications.
Morey, L., Warner, M., and Boggs, C. 2002. “Gender Bias in the Personality Disorders
Criteria: An Investigation of Five Bias Indicators.” Journal of Psychopathology and Behavioral Assessment, 24, 1, 55-65.
Morrison, J. 1995. DSM-IV Made Easy. New York: Guilford Press.
Murphy, D. 2001. “Hacking’s Reconciliation: Putting the Biological and the
Sociological Together in the Explanation of Mental Illness.” Philosophy of the Social Sciences. 31, 2, 139-162.
Nehls, N. 1998. “Borderline Personality Disorder: Gender Stereotypes, Stigma, and
Limited System of Care.” Issues in Mental Health Nursing, 19, 97-112.
Owens, C. 1985. “The Discourse of Others: Feminists and Postmodernism.” In H.
Foster (ed.) Postmodern Culture. London: Pluto Press. 57-79.
Padilla, A.M. 1995. Hispanic Psychology: Critical Issues in Theory and Research.
Newbury Park, CA: Sage.
Parsons, T. 1951. The Social System. New York: Free Press.
Pilgrim, D. 2005. Key Concepts in Mental Health. London: Sage.
Plath, S. 1962. “Daddy.” in Plath: Poems. New York: Everyman’s Library.
Plechner, D. 2000. “Women, Medicine, and Sociology: Thoughts on the Need for a
Critical Feminist Perspective.” Health, Illness, and the Use of Care: The Impact
of Social Factors. 18, 69-94.
Rimke, H. 2000. “Governing Citizens Through Self-Help Literature.” Cultural Studies.
14, 1, 61-78.
Rimke, H. and Hunt, A. 2002. “From Sinners to Degenerates: The Medicalization of
Morality in the 19th Century.” History of the Human Sciences. 15, 1, 59-88
Rimke, H. 2003. “Constituting Transgressive Interiorities: 19th-Century
Psychiatric Readings of Morally Mad Bodies” in A. Aldama (ed.) Violence and
the Body. Bloomington: Indiana University Press.
Rimke, H. Forthcoming, 2009. “Pathological Theories of Crime and Criminality” in
Kirsten Kramar (ed.) Introduction to Canadian Criminology. Toronto: Pearson Education Canada.
Rose, N. 1986. “Psychiatry: The Discipline of Mental Health.” in Peter Miller and
Nikolas Rose (eds.) The Power of Psychiatry. Cambridge: Polity Press. 43-84.
Ross, L. 2004. “Book Review.” Archives of Women’s Mental Health, 7, 2, 151-152
Russell, D. 1987. “Psychiatric Diagnosis and the Oppression of Women.” Women and
Therapy. 5, 4, 83-98.
Schroeder, B. (dir.) 1992. Single White Female. Perf: Bridget Fonda, Jennifer Jason
Lee, Steven Weber. Columbia Pictures Corporation.
Sexton, A. 1960a. “Her Kind.” in To Bedlam and Part Way Back. New
York: Mariner Books.
Sexton, A. 1960b. “Music Swims Back to Me.” in To Bedlam and Part Way Back.
New York: Mariner Books.
Shaw, C. and Proctor, G. 2005. “Women at the Margins: A Critique of the Diagnosis of
Borderline Personality Disorder”. Feminism and Psychology, 15, 4, 483-490.
Smith, D. 1975. “Women and Psychiatry.” Smith, D. and David, J (eds.). 1975.
Women Look at Psychiatry. Vancouver: Press Gang Publishers.
Sparti, D. 2001. “Making Up People: On Some Looping Effects of the Human Kind –
Institutional Reflexivity or Social Control?” European Journal of Social Theory.
4, 3, 331.
Szasz, T. 2007. Coercion as Cure: A Critical History of Psychiatry. New Brunswick:
Szasz, T. 1974. The Myth of Mental Illness. New York: Harper Collins.
Trull, T. J. and Widiger, T.A. 2003. “Personality Disorders.” in G. Stricker, T.A.
Widiger, and I.B. Wiener (eds.) Handbook of Psychology: Clinical Psychology, Volume Eight. New York: Wiley. 149-172.
Turner, R. and Edgley, C. 1983. “From Witchcraft to Drugcraft: Biochemistry as
Mythology.” Social Science Journal. 20, 4, 1-12.
Ussher, J. 1991. Women’s Madness: Misognyny of Mental Illness? Amherst: University
Of Massachusetts Press.
Ward, S. 1996. “Filling the World With Self-Esteem: A Social History of Truth
Making.” Canadian Journal of Sociology. 21, 1-23.
Wirth-Cauchon, J. 2001. Women and Borderline Personality Disorder: Symptoms and
Stories. New Brunswick, NJ: Rutgers University Press.
Wodak, R. and Meyer, M. 2001. Methods of Critical Discourse Analysis. London:
Zanarini, M. 2005. Borderline Personality Disorder. Boca Raton: Taylor and Francis.
 Western culture, and most extremely American culture, which will be discussed in detail in chapter four when examining the case of rhetoric regarding “good versus evil”, is infused with binary logic. The term “binary”, conceptualized by Derrida (Derrida 1978:194), refers to a rhetorical accomplishment achieved by defining two concepts in terms of their opposition to one another, effectively constraining thought and discourse by failing to acknowledge that conditions that defy the binary exist.
 In his conceptualization of genealogy, among other projects, Foucault makes the distinction of not defining “power” or “control” as inherently “good” or “bad”, but examines who possesses power, how they use it, and what the results are (see Elden 2006, Foucault 1977a).
 The meaning of this adjective, “hysterical”, when it came into common usage in the seventeenth century, is quite ambiguous; a better understanding of it would require extensive archival research and a rigorous examination of remaining texts from that period.
 Interestingly, frequent masturbation, as well as the enjoyment of the act, was yet another behaviour that was attributed to hysteria by psychoanalysts (see Freud 1905).
 Psychocentrism refers to a culture characterized by an obsession with the self – as the locus of all one’s woes, but also the sole vehicle by which the individual may realize his ideal life and achieve “contentment”. Psychocentrism is an asset to governers in neo-liberal societies, as it creates self-regulating citizens. The government does not have to expend as many resources to mould people into model citizens, as people do this voluntarily, based largely on the “expertise” offered by members of the psy-establishment (Rimke 2000:73).