Personality Disorder Diagnoses Should not Depend on Gender
Beware of gender stereotypes leading to misdiagnosis.
Personality disorder criteria can look different amongst genders.
Histrionic and Dependent Personality Disorders are more common in men than you might think.
Accurate diagnosis relies on observing personality patterns, not jumping to conclusions based on one chief component and gender.
"Who's the new guy?" I asked the officer as a particularly-animated man closed in. "That's Bobby (name disguised). Came in a few days ago. What you see is what you get. He's either all-a-dither or trying to impress the guys. Not mixing well."
Seconds before, "Sir, siiiir! I can't be locked up here with all these heathens!" rang out in a flamboyant southern drawl. Looking over my shoulder, there was no missing the man in an orange jumpsuit flouncing towards me in nuclear distress mode. His inmate peers merely glanced up at the distraction, then returned to their exercising or games. For me, there was no escape: Bobby was looking for a savior, and he had me pegged.
A befuddling first encounter
Speaking to me as if we'd known each other a lifetime, Bobby pleaded his case in theatrical desperation. A pressured account of being a scrupulous man unlike his inmate peers, and that he was just visiting from out of town and was in the wrong place, gushed for several minutes. Eventually, I made a successful interjection and obtained some history.
Indeed, Bobby liked to make an impression. As he noticed I was paying attention, distress transitioned to a more flashy side. Out came details of his worried, trophy girlfriend; important social commitments being missed, how he planned to hire the highest-powered attorney, and would his Fossil watch be safe in the property storage room? For all the earlier anxiety, Bobby made a few jokes, too.
What was that?
"What a strange presentation," I thought to my budding clinician self as Bobby exited. This was followed by, "Was that lability and grandiosity hypomania? Is he maybe within the narcissistic realm?" The truth was, if Bobby were a Bobbie, I likely would've surmised a histrionic personality.
Years later, at a training by the gifted psychoanalyst Glen Gabbard, MD (2015), I learned that my mistake wasn't uncommon. Dr. Gabbard expounded on how diagnostic gender bias abounds amidst the narcissistic and histrionic personalities.
If it's a male that presents as Bobby, he noted, chances are it'll be chalked up to narcissism; a female, histrionic. Dr. Gabbard explained the histrionic personality is actually more gender-equal, also noted in the DSM-5, but noted that traditional images favored the diagnosis be reserved for females. Males indeed often meet criteria, but with a different flavor. As I gained more experience, I learned that Bobby's presentation was typical of histrionic males.
As noted by many researchers and authors over the years (i.e., Morey et al., 2002; Boysen et al., 2014; Skodol et al. in Weiss-Roberts, 2019), diagnostic mistakes in personality disorders regularly occur due to gender-related matters. Morey et al. (2002) observed that some personality disorders are readily-perceived as "a disorder as a function of gender," which seem enforced by some criteria descriptions (further detailed below).
Personality expert Stuart Yudofsky, MD (2005) continued on this in terms of cases like Bobby's. He explained, that, despite ongoing researcher recognition of gender-equal prevalence in histrionic personalities, the historical lens is likely to continue to present issues. Essentially, there's a strongly-rooted historical tendency to equate histrionic personality with females, and attention-seeking is often through flirtatious/sexualized behavior. Since this behavior is typically portrayed as a feminine activity in popular culture, and even described in the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM) as the way attention is usually sought by histrionic people, it’s easy to see how if this feature is lacking, we may not think "histrionic."
Gender presentation differences in histrionic personalities
If we are to reduce gender-based diagnostic errors with presentations like Bobby, it must be realized that the male presentation does not usually fit that mold.
Both genders exhibit unmistakable core features of affective lability and a tendency for over-familiarity. They both are also very attention-seeking and may be interested in superficialities. However, males with histrionic personalities tend to exhibit their attention-seeking through palling around, being the jokester, or trying to impress with superficialities other than looks, though that certainly is not out of the question.
This form of gregariousness is what tends to stand out, and the patient likely appears self-absorbed, the requisite foundation of narcissism. Given the unfortunate circumstance that people are often diagnosed based on one core feature, as discussed in Tips for Accurate Diagnosing: One Symptom Isn’t Enough, it’s easy to see how this could lead to diagnosing the person as narcissistic. Further, Dr. Nancy McWilliams (2013) noted, “Because hysterically [histrionic] organized people use narcissistic defenses (e.g., compensatory needs for acceptance and reassurance) they are readily interpreted as narcissistic characters.”
However, as well-illustrated in Millon (2011), a histrionic person uses superficialities to draw people in for emotional gratification and are capable of warmth. A narcissist, on the other hand, uses superficialities to impress someone they'd like a relationship with that will either up their status or can otherwise be exploited. A narcissist also would never want to appear dependent on someone for anything, as illustrated by my first encounter with Bobby, and continued in other encounters. As I got to know him, Bobby also didn’t exhibit the lack of empathy or profound entitlement present in narcissism.
Ironically, perhaps the best example of a narcissist ever caught on recent film was Meryl Streep's character Miranda Priestly in The Devil Wears Prada.
When personality disorder and gender discrepancy are mentioned together, what's most likely to be discussed is the erroneous "Borderline is for females, Antisocial is for males" perception, as if they're the same disorder called something different in their respective genders (e.g., Paris et al., 2013; Hulthausen & Habel, 2018). As illustrated herein, the histrionic and narcissistic have a similar tendency for gender bias, and it also seems rare a male is diagnosed as dependent (e.g., Klonsky et al., 2002; Disney, 2013; DSM-5, 2013).
Many males suffering from Dependent Personality Disorder may be falling through the cracks due to gender stereotypes. To illustrate, over the years, when I’ve worked with couples that include a Dependent male, the wife’s complaint was often that the husband was lazy and spineless. Upon further examination, she viewed him as lazy because he didn’t make decisions, didn’t take on substantial responsibilities, and avoided conflict, especially with her. These are all signs of a dependent personality, but a male is not likely to be perceived as being dependent on a female, and it was chalked up to a lazy temperament.
A simple exercise can help prevent gender-based misdiagnosis. If you’re considering ruling in or ruling out any of the five conditions mentioned herein (Antisocial, Borderline, Histrionic, Narcissistic, or Dependent), reflect on whether gender is influencing your decision. It could be the deciding factor if someone receives the intervention they require for success.
Disclaimer: The material provided in this post is for informational purposes only and not intended to diagnose, treat, or prevent any illness in readers. The information should not replace personalized care from your provider or formal supervision if you’re a practitioner or student.
Anthony Smith, LMHC, has 20 years of experience that includes the roles of therapist, juvenile court evaluator, professor, and counseling supervisor.