Abstract
Purpose. To explore the experiences of women diagnosed with borderline personality disorder (BPD) from a holistic perspective, incorporating their experiences in the social and health fields and their perception of motherhood, and to analyse the influence of the social construction of gender. Design and Methods. Qualitative study with a hermeneutic phenomenological design. Eight women with a diagnosis of borderline personality disorder participated in the in-depth interviews. Findings. The trauma, stigma, and difficulty associated with motherhood and being a woman are determinants in the experience of symptoms and the recovery from them. Practical Implications. The findings offer keys to improving the quality of women’s nursing care and the treatment they are provided according to gender factors.
1. Introduction
Borderline personality disorder (BPD) is defined as a pattern of instability in one’s social relationships, self-image, and affectivity, and entails marked impulsivity [1, 2]. People diagnosed with BPD are characterized by an intense fear of abandonment, real or imagined [1, 2]. Therefore, they frequently show intense reactions of anger and anguish as well as impulsiveness, self-injurious behaviours, and suicidal behaviours or threats [3]. Their relationships are often very intense and fluctuating [3], and their self-image is characterized by sudden changes in areas such as their values, identity, or desired future [1, 3].
In the childhood histories of people diagnosed with BPD, physical and sexual abuse, carelessness, and early loss of and separation from parents are frequent [2, 4]. It has been observed that a high percentage of people with a diagnosis of BPD report experiencing severe trauma throughout childhood [5]. Sexual abuse and traumatic childhood experiences are considered as one of the greatest predictors of the development of the disorder [5].
The DSM V estimates the prevalence of BPD among women at 75% [1], although there are diagnostic biases related to gender [2, 6]. The clinical manifestations seem to be more severe and reveal a greater predisposition towards the internalization of symptoms in women than to their externalization in men [7–10]. Therefore, it has been theorized that these manifestations may be related to the extreme representation of characteristic gender traits.
Gender construction is defined as a system of relationships that establishes values and social norms, through which women and men are produced and normalized with respect to the feminine and masculine models (in a heteronormative binary system). Therefore, it encompasses social attributes, roles, and behaviours, as well as the ideals and subjective components of feminine and masculine identities, which will be transmitted through socialization [11, 12]. Addressing health problems from a gender perspective requires understanding the differences in the socialization of men and women, which determine the different values and behaviours, differences in access to resources, and the sexual division of labour, and that these factors influence both the health of women and men [13]. This makes it possible to detect the risks and problems that they suffer in a particular way, understand the differences in terms of experiences, and identify the most convenient forms of prevention and treatment for women and men. The experiences of people with BPD have been scarcely studied from a gender perspective. Qualitative studies have focused on the experience of women [14–20] and discussed a predominance of negative emotions, experiences of nonexistence, losses of control, and death wishes [14, 15]. The prevalence of traumatic events during childhood is a striking factor related to the feeling of abandonment and rejection during adulthood, as well as the need to be accepted and validated, and to the feelings of shame and guilt towards oneself [16, 21].
Experiences in the health field are marked by apparent discrimination and a lack of understanding by health professionals, especially nurses [19, 20, 22], and by stereotypes associated with a BPD diagnosis [17, 18]. Social relationships are considered essential for recovery [15]. However, people with BPD find it difficult to create and maintain significant and stable relationships due to their own difficulties, the influence of stereotypes [17], and the prevalence of situations of violence and abuse in their environment [17, 23].
Regarding the experience of motherhood, it is a process of special vulnerability due to the stressful changes that it introduces in the lives of mothers, especially in terms of acquiring a new role, changes in the relationship with their partner, and the need to be supported to adapt to the life changes they have to face, as well as the mixed feelings that arise [24]. There are difficulties BPD adds in relation to the parenting process [25–28]. It seems that there is a generational transmission of BPD when learning maternal roles [27]. The high emotional intensity related to this process can also trigger complicated family situations [26], while the difficulty of mentalization makes it more difficult for people with BPD to understand the emotional needs of their children [25]. Women themselves report a high level of anxiety and express their feelings of guilt and concern regarding the impact that their difficulties may have on the development of their children [28].
1.1. Aim
Various studies [7–10, 16] have discussed the disparate clinical presentations of people diagnosed with BPD in relation to gender construction. However, few studies have explored the experiences of people with this disorder by focusing on the weight of social roles in their development and the difficulties these people face.
The difficulty of health professionals, particularly nurses, when providing care to people with BPD, due to the associated stigmas, has been studied [22, 29, 30]; this hinders the provision of quality care. To improve the quality of care provided via nursing, it seems relevant to explore and describe the experiences of women diagnosed with BPD from a holistic perspective, incorporating their perceptions of motherhood and experiences in the social and health fields while analysing the influence of the social construction of gender. This could help nurses to better understand the experiences these women have gone through, the reasons they behave the way they do, and to empathize with them, so that they can better comprehend their care needs and establish a better therapeutic relationship.
2. Methods
2.1. Study Design
The objective is to deepen the understanding of the experiences of women diagnosed with BPD that result from this diagnosis, delving into its impact on their social relationships, on their perception of the health system, and on their motherhood experience, considering the gender construction. A qualitative methodology with a hermeneutic phenomenological design was selected, following the principles of Heidegger [31].
2.2. Setting and Participants
The participants were women over 18 years of age diagnosed with BPD, who had been under treatment in HUJG for more than one year after their diagnosis, to ensure that they could clearly discuss their own experiences afterwards. For recruitment, professionals from different units of HUJG were informed by the main researcher about the criteria and objectives of the study, and they proposed possible informants based on them. Women were approached by their referral therapist, who explained to them the possibility of participating in the research; those women who agreed to be contacted were approached by the researchers through telephone to provide them with the information regarding the investigation and to make an appointment for the interview in case they finally agreed. None of them refused to participate. Any women who might have difficulty in understanding or speaking Spanish and those who presented clinical symptoms at the time of the research that prevented or discouraged their participation were excluded. Convenience sampling was performed; later, according to our analysis of the data, we applied a theoretical sampling by taking into account the profiles of interest based on the information needs we had detected, to ensure maximum discourse variability [32]. The sample size was determined using the data saturation principle [32], resulting in a total of 8 women.
2.3. Data Collection
Data collection was carried out at the José Germain University Hospital (HUJG), between September 2020 and November 2021. In-depth, semistructured, and individual interviews were carried out with a script of open-ended questions, detailed in Table 1, each lasting between 45 and 90 minutes [32]. They were recorded with audio support with the consent of the participants.
During this study, the health crisis due to COVID-19 began; thus, some interviews were conducted through the virtual videoconferencing platform Jitsi [33]. Other interviews were conducted in person while respecting the sanitary measures imposed by the Ministry of Health [34]. A room in HUJG was chosen that allowed adequate sanitary and privacy conditions [32], where only the interviewee and interviewer were present. The interviews were conducted by the main researcher and supervised by other researchers of the team, who had extensive previous experience in conducting in-depth interviews.
2.4. Data Analysis
Thematic analysis was performed following Smith et al. [35]. The interviews were transcribed in their entirety, and then reading, coding, and categorization were carried out, which allowed the generation of a framework of relevant meanings. The computer software NVivo was used.
To ensure the rigor and quality of the results, the COREQ criteria were taken into account [36]. Validity and credibility were used as rigor criteria, making the transcriptions of the women’s experiences and using the generated verbatim to carry out the interpretative analysis. To determine this credibility, triangulation of the data was also increased with an external researcher, an expert in qualitative research, who was invited to a presentation session. The results were also contrasted with the literature. In the same way, the analysis was verified with several informants, which ensured greater credibility via this feedback [32].
This study meets the transferability criterion because an exhaustive description of the entire context and participants has been made; therefore, the results obtained can be transferred to groups with similar characteristics. In the same way, complete data collection has been used, making the verbatim give dependability to this study. Finally, the research team has acquired a commitment by reporting its position in the work, showing its confirmability [37].
2.5. Ethics
The following basic legal and bioethical principles of research were taken into account: beneficence, nonmaleficence, justice, and autonomy [38]. This study was approved by the Directorate of HUJG and by the Clinical Research Ethics Committee (CEIC) of Severo Ochoa University Hospital (Minute 03/20 (25/03/2020)). The participants were informed of the study and their ARCO rights, and their voluntary signing of informed consent was requested for their participation and the recording of their interviews, guaranteeing the possibility for revocation. Confidentiality was ensured through coding, and accessibility was guaranteed to be granted only to the principal investigator.
3. Results
3.1. Patients: Sociodemographic Characteristics
Eight women with an average age of 43 years and an average mental health follow-up time of 9.6 years participated in the research. All of them had been admitted to a brief psychiatric hospitalization unit at least once. In addition, 7 of the 8 participants had children. The characteristics of the sample are detailed in Table 2.
3.2. Analysis of Thematic Content in the Discourses
The results obtained from the analysis of the discourses of the participating women have been organized into thematic areas with corresponding subtopics according to the revealed meanings, as shown in Tables 3 and 4.
3.2.1. Fatal Childhood, Fatal Teenagerhood
There is a great emotional instability that began in childhood, with feelings of sadness and loneliness being predominant. The presence of devastating events in the immediate environment is characteristic. In some cases, follow-up via mental health services begins at this time, as a consequence of emotional and behavioural problems.
The informants related their current suffering to experiences suffered in childhood. The expression of insecurity and fear within the family is common, with parents defined as unstable, unpredictable, and even violent, verbally or physically. In several interviews, experiences of sexual abuse by close relations, sometimes family members, were mentioned. The informants themselves consider these facts as important triggers of their symptoms of the disorder.
3.2.2. My Dark World: What I Have
Feelings of sadness, depression, and emotional instability predominate, which produces limitations in day-to-day life. Sometimes, these are related to the withdrawal of important people or the perception of a lack of help. In addition, they are described as the reason informants interpret reality in a disproportionate way—manifesting extreme ideas in relation to the events involving or intentions of others. Their consequent impulsive reactions are described as one of their main difficulties, as they pose a problem when creating and maintaining relationships.
Emphasis is placed on the loss of control of one’s own actions in situations of high emotional burden and the ability to cause harm in those moments, both to other people and themselves. Aggression manifests itself verbally or even physically in the form of an attack or self-harm. They consider these reactions both “abnormal” and inevitable at the time of a crisis. Sometimes, there is regret, or even fear of oneself or one’s own reactions. In other cases, there is no regret because there is no clear memory of what happened.
On the other hand, there is the discussion of suffering experienced throughout life and the inability to enjoy experiences, as well as of the insecurities and fears that increase with the development of BPD symptoms. Ideas of death are frequent, recurrent, and ongoing, together with autolytic gestures of varying severity. Frustration is sometimes expressed as the inability to commit suicide. In general, these ideas increase in moments of greater crisis and suffering.
Regarding their experience with the BPD diagnosis, in general, this is perceived to be an imposed label with which they do not identify. For some women, it cannot effectively explain what happens to them; they consider it too nonspecific. Others do not believe that their problem is part of the disorder since they do not feel sick. Rather, they relate this label to the stereotypes that are socially attributed to it, associating it with immature or capricious people, which produces their rejection of a diagnosis they deem stigmatizing.
3.2.3. Large Stigma: You Are Seen as a Weirdo
Social and family relationships, from which they do not receive the support they need, are considered scarce. There is a perception of distancing, especially when there are episodes of crisis or self-harm. Reference is made to their experience of emptiness, related to their feeling of abandonment and lack of social support.
The informants perceive a dichotomy regarding social stereotypes, since they feel that they are not only treated as “crazy” or “weird”—incapable of making important decisions—but also expected to function normally, especially with regard to the care of children and the home. Therefore, these women believe that it is important for professionals to provide adequate information to their support team to ensure they can help them in the recovery process.
Few informants have support from other people. They highlight their presence throughout the experience with the disease, their proportion of affection, and the fact that they have not abandoned them. Feelings of guilt arise in relation to those whom they consider they have hurt, since they think that abandonment is the norm.
Some informants shared their experiences as primary caregivers. Often, they are the only ones responsible for the care of their children or parents, which makes it difficult to attend psychotherapeutic treatment. They mention the questioning of some professionals regarding their participation in treatment due to the frequent absences driven by their care tasks, which they interpret as punishment, despite the effort they have put into treatment.
Feelings of guilt and suffering are frequent due to the inability to dedicate the time or effort they consider necessary for such care, either due to their psychopathological situation or the occasional need to delegate this care to others. Their guilt is greater when their children have witnessed crises or have been victims of their manifestations of aggression—frequently triggered by family conflicts with high emotional burden. They consider support essential to perform care tasks, especially in periods of instability, since they are unable to adequately carry out this role alone.
On the other hand, their family and children are mentioned as one of the main reasons they do not perform more autolytic gestures, or they continue to struggle to maintain stability. Sometimes, their children themselves have become the caregivers of the informants.
3.2.4. Attention of Professionals
The informants’ experiences with health professionals seem generally good. They value the feeling that they have been given real attention, understanding, a sense of connection, and the security of being able to request professional help if they are in a crisis situation, as well as the perception that “everything is done for them.” Interventions based on the prescription of psychopharmacological treatment are perceived to be insufficient. In general, these lack closer proximity and a more personalized treatment.
On the other hand, they consider that their treatment is different from that for people with other mental health problems, referring to a stigma associated with the diagnosis of BPD. They appreciate a treatment that is not focused on this diagnostic label but on their own needs, making them feel more empowered in the process.
The experiences in hospitalization units are generally negative among women with greater behavioural problems; they mention having been treated “like fools” or “like dogs.” In addition, there is the discussion of theexcessive use of psychotropic drugs and mechanical restraints as attempts to resolve crisis situations, which they interpret as punishment. They describe the sensation of feeling as “prey” in these units due to their closed and routine structure, with excessive norms that they consider extreme and even violate their privacy, whereby they feel that they lose their autonomy. This leads to them not asking for help in crisis situations for fear of punishment. Regarding the ways to improve this experience, they suggest that there should be greater closeness, with less treatment based on surveillance, and they believe it is important to develop new intervention tools for professionals with an approach to crisis situations that allows a perception of help and care.
4. Discussion
Early attachment problems are considered one of the main factors in the development of BPD [39]. Among the women participating in this study, their memories of childhood and adolescence are impregnated with negative emotions, such as fear, loneliness, or sadness. These expressions arise from experiences in their family environment in narrations of violent events, rejection and abandonment, insecurity and instability of the home itself, and a sense of a lack of care and expressions of affection. According to Fonagy [40], 92% of people with BPD have an insecure attachment style, characterized by inconsistency in parental care. In addition, numerous studies [4, 21, 41, 42] have found a very significant relationship between experiences of parental abuse and neglect in childhood and the symptoms of BPD. Reports of sexual abuse during the childhoods and adolescence of the participants should also be noted. Such abuse has been described as one of the main predictors of the development of BPD [39, 43].
It is interesting that trauma is not one of the diagnostic criteria for BPD in the DSM [1]. Therefore, its use as a way to deny the importance of abuse, trauma, and oppression in psychological distress has been discussed [44], especially when it is suffered by women. We must take into account the relationship between trauma and gender and the violence exercised against women as a result of the power relations in their family environment, community, and institutions themselves [43, 45]. In addition, abuse in childhood and adolescence seems to have different consequences according to the sex of its victims, with more internalization problems such as depression, anxiety, and isolation in women according to a recent report on child abuse in the family in Spain [46], which could lead to different diagnoses in adulthood in similar trauma situations [6].
Regarding the most problematic revealed difficulties, the informants highlighted emotional and behavioural instability. These results coincide with those in previous studies [21, 39, 47, 48] where the inability to tolerate negative emotions has been explored; specifically, they resort to maladaptive coping mechanisms, such as self-harm or self-harm attempts [48]. Self-destructive behaviours are repeatedly mentioned in the discourses of the informants in this study. Self-injurious behaviours often result from impulsive behaviour due to the inability to handle intense negative emotions [21, 39, 47], serving as an attempt to regain control and change an experience from emotional pain to physical pain, which is easier to bear [39]. According to various studies [45, 49, 50], self-harm with BPD is more frequent among women due to their greater tendency to act via self-harm. In contrast, in autolytic attempts, with the same frequency between sexes, lethality among men is higher due to the means that are used.
In moments of emotional crisis, dissociative experiences are narrated with a lack of awareness of what is happening; this phenomenon has also been frequently described in the literature [39, 50] as a consequence of early trauma and as a way of dealing with situations that one cannot effectively address.
Regarding their experience with their diagnosis, the participants defined it as an external imposition with which they do not identify. According to Lamont and Dickens [51], this is the case for a large proportion of people diagnosed with BPD; however, for some of them, their diagnosis provides relief and a sense of control and hope [39, 52]. With respect to the imposition of this diagnosis, Chesler [53] and other authors [44, 54] notably mention a pathologization of female traits through diagnoses such as BPD—an argument that agrees with that of Caroll Gilligan [53] in relation to gender biases in science.
With respect to their social and family relationships, the informants reported a great scarcity of them and their perception of abandonment and rejection, usually due to the appreciation of their symptoms. This is consistent with various studies [17, 21, 55, 56] that also mention a greater predisposition of people diagnosed with BPD towards remembering social situations with a negative connotation [55] and a lower capacity to enjoy them [56]. Moreover, the importance of social relationships in the recovery process has been highlighted by numerous studies [15, 39, 57–60].
Notably, the experiences of stigma among the participants comprise both treatments based on stereotypes and normalizations of their suffering. This dichotomy has been described in other articles [17, 61], which have also revealed a greater stigmatization of BPD than other disorders due to social incomprehension of its manifestations. This normalization of suffering has been associated with social stereotypes imposed on the female condition in relation to frailty and care-seeking; this theory relates to the ideas on exclusive binary representations proposed by Soley-Beltran [62].
Regarding the relevant care tasks, our results agree with the literature [25–27, 43, 63] in which barriers to the access of treatment by women with dependents are exposed, particularly the lack of consideration by health professionals in this situation. Studies mention difficulties exercising the role of mother in periods of instability, which produces guilt, suffering, and a feeling of incapacity—emotions closely linked to the mandates imposed on mothers [63]. Such experiences are articulated in Bartsch et al. [63], e.g., difficulties maintaining a stable environment for children, and in Dunn et al. [26], e.g., struggles recognizing the emotions of children and responding proportionally. In addition, moments when children become caregivers, as well as when overprotective behaviours are performed in compensation, are highlighted [26, 63]. It seems necessary to consider the adaptation of health services to the profile of users who perform care tasks to prevent marginalization via resources, and on the other hand, to carry out interventions that take into account the role of motherhood, fostering improved coping and the acquisition of parenting skills, to help prevent the generational transmission of mental health problems [25–27, 63].
On the other hand, their experiences with health professionals were described by the informants as marked by stigma, distance, and even trauma when in hospitalization units. The stigma of professionals towards BPD has been widely described [51, 52, 57, 61, 64], as has the negative consequences associated with the quality of care [52]. Regarding hospital units, other studies [51, 64] agree with our findings, i.e., they provide a more negative experience than other types of services due to greater medicalization of the process and excessive rigidity and paternalism, in addition to, as expressed by the informants, the need for greater training of professionals in terms of patients’ problems and listening and comprehension skills. Previous research [52, 59, 64] has similarly recommended facilitating the understanding of the suffering of people with a diagnosis of BPD through the transmission of their experiences in their own voice.
5. Conclusions
The childhood experiences of the informants have been marked by a series of traumatic events that influence the development of their disorder and suffering in adulthood. During the maturity of these women, the predominant feelings are negative. In addition, impulsive reactions are a main problem for them; they make it difficult to maintain a satisfactory life. Social and family relationships are marked by this type of reaction, the presence of stigma, and the underestimation of suffering. Relationships with health professionals are affected by this stigma, especially in the hospital environment.
Informants’ motherhood and parenting are marked by their difficulties with this process itself, which cause guilt, suffering, and the feeling of inability to exercise the role of mother. Care by health professionals during these processes is scarce.
In all these areas, to properly understand the experiences and traumas experienced throughout the life of these women, the stereotypes and social norms imposed on them must be considered.
5.1. Implications for Nursing Practice
The present study allows nurses to better understand the care needs among women with BPD. We must consider the need to incorporate families into the illness and recovery process to improve the understanding of the needs of these women, since this factor could affect their recuperation. In addition, we must be aware of the requirements and difficulties of such women who exercise a caregiving role, of the need to adapt services to these needs, and of paying attention to the process of motherhood in our interventions.
On the other hand, the improved understanding of the first-person suffering of women with BPD—through studies such as this one—could help reduce the associated stigma, and in this way, improve the quality of care provided to these women.
Data Availability
The data set used and analysed during the current study is available from the corresponding author upon reasonable request.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Authors’ Contributions
Nerea De-la-Morena-Pérez, Inmaculada Corral-Liria, and Raquel Jiménez-Fernandez were involved in the design of the study. Nerea De-la-Morena-Pérez collected the data for the study. Inmaculada Corral-Liria, Javier Sánchez-Alfonso, and Ricardo Becerro-de-Bengoa-Vallejo undertook the background literature search. Marta Losa-Iglesias, Nerea De-la-Morena-Pérez, and Raquel Jiménez-Fernandez undertook the data analysis and drafted initial versions of the paper. All the authors made substantive contributions to the final submitted paper.