Psychiatry (Edgemont) 2010;7(4):21–30

by Ashley B. Johnson, DO; Julie P. Gentile, MD; and Terry L. Correll, DO
Dr. Johnson is a Fourth Year Resident, Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio. Dr. Gentile is Associate Professor, Department of Psychiatry, Boonshoft School of Medicine, Wright State University. Dr. Correll is Assistant Professor, Department of Psychiatry, Boonshoft School of Medicine, Wright State University.

Psychiatry (Edgemont) 2010;7(4):21–30

Funding: There was no funding for the development and writing of this article.

Financial disclosure: The authors have no conflicts of interest relevant to the content of this article.

Editor’s note: All cases presented in the series “Psychotherapy Rounds” are composites constructed to illustrate teaching and learning points and are not meant to represent actual persons in treatment.

Key words: psychotherapy, bipolar disorder, borderline personality disorder, diagnostic dilemma

Abstract

The high prevalence of comorbid bipolar and borderline personality disorders and some diagnostic criteria similar to both conditions present both diagnostic and therapeutic challenges. This article delineates certain symptoms which, by careful history taking, may be attributed more closely to one of these two disorders. Making the correct primary diagnosis along with comorbid psychiatric conditions and choosing the appropriate type of psychotherapy and pharmacotherapy are critical steps to a patient’s recovery. In this article, we will use a case example to illustrate some of the challenges the psychiatrist may face in diagnosing and treating borderline personality disorder. In addition, we will explore treatment strategies, including various types of therapy modalities and medication classes, which may prove effective in stabilizing or reducing a broad range of symptomotology associated with borderline personality disorder.

Introduction

Borderline personality disorder (BPD) is a highly prevalent, chronic, and debilitating psychiatric problem characterized by a pattern of symptoms that may include chaotic and self-defeating interpersonal relationships, emotional lability, poor impulse control, angry outbursts, frequent suicidality, and self-mutilation.[1] It is not uncommon for the psychiatrist to see symptoms of both bipolar disorder (BD) and BPD, which creates a diagnostic dilemma that must be distinguished by the time of treatment initiation due to their diverging methods of approach. There are similar symptoms that may be seen in clinical presentations of both of these psychiatric disorders (Table 1 Table 2 Table 3 Table 4 Table 5).[2]

The treatment of choice for BPD remains psychotherapy.[1] In this clinical vignette, the authors will review some of the common issues that present themselves as the psychiatrist navigates this often challenging professional relationship.

Clinical Case

Brittany was a 22-year-old, single woman who presented for psychiatric consultation for ongoing management of BD.

Brittany was first diagnosed with BD as an unruly 16-year-old high school student. Subsequently, she had been seen by multiple psychiatrists for this disorder and had been prescribed multiple mood stabilizers, including gabapentin (Neurontin, Parke-Davis: Division of Pfizer Inc, New York), lamotrigine (Lamictal, GlaxoSmithKline, Research Triangle Park, North Carolina.), and valproic acid (Depakote, Abbott Laboratories, Abbott Park, Illinois). Most recently, she reported an overdose of valproic acid, which required a five-day stay in an intensive care unit; no subsequent inpatient psychiatric hospitalization was recommended. At the time of discharge, she assured the doctors that she was “fine,” that “it was a stupid thing to do,” and she verbally contracted that she would never try to overdose again.

During intake interview following the hospitalization, while she initially characterized her formative years as “good” with no report of any abuse, it became apparent that she had endured significant neglect from her parents, both of whom worked full-time to provide for the family.

Brittany described her symptoms of BD as starting at about the age of eight when she remembers it was necessary for her mother to seek full-time employment.

She remembered always having variable moods being “up and down,” which were consistently correlated with multiple relational triggers in her life. As an example, she described being “manic” after a boy showed interest in her at school. Her ‘manic’ episode included increased energy and excitement, texting her friends up to a couple hundred times a day, shopping tirelessly to find the right outfit to wear for him, and noticing an increased sexual drive; her family members commented on her energetic behavior. When peers would tease her about being “easy” or she suspected her boyfriend was flirting with another classmate, she would seemingly lose control by yelling obscenities in an angry, uncontrolled rant.

These “manic” episodes could occur frequently (up to several times daily) depending on how many good things happened in her life and typically would last several hours at a time.

During the first interview, Brittany’s speech was very rapid as she described her situation. The psychiatrist initially concluded that she was “pan-positive” on nearly every symptom of BD, but wanted additional time to consider possible axis II pathology. Psychotherapy had never been offered as part of the treatment recommendations; pharmacologic management had been the focus of her treatment thus far.

PRACTICE POINT

Diagnostic dilemma: BP versus BPD. BPD and BD, and particularly BD II, prove to be diagnostic dilemmas for practitioners due to the high occurrence of symptom overlap. Both disorders are associated with a considerable risk of suicide or suicide attempts, impulsivity, inappropriate anger, and unstable relationships.[3] However, many symptoms are particularly common in BPD to include self mutilation, self-injurious behavior without suicidal intent, and a stronger association to a childhood history of abuse. Insecure attachments, signified by an intense fear of abandonment, are hallmarks of BPD and not typical characteristics of BD.[3] Patients with BPD also demonstrate a higher level of impulsivity, hostility, and acute suicidal threats when compared to patients with BD.[3] Furthermore, Fiedorowwicz and Black[3] suggest careful history taking usually elicits a differing time course of mood lability: “Mood lability of BPD often is produced by interpersonal sensitivity, whereas mood lability in bipolar disorder tends to be autonomous and persistent.”[3]

Widiger and Mullins-Sweatt[4] delineate a time course of BPD symptoms over a lifetime. Early in life, patients are likely to have been emotionally unstable, impulsive, and hostile, although, thus far, research has not clearly defined childhood antecedents of BPD.[4] Normal adolescence often involves rebellion or identity diffusion problems; however, the development and intensity of BPD traits in an adolescent may precipitate involvement in rebellious groups.[4] These maladaptive traits may also contribute to the development of various axis I disorders including post-traumatic stress disorder and other anxiety disorders, eating disorders, substance-related disorders, attention deficit hyperactivity disorder (ADHD), and mood disorders.[4,5,12]

As the patient with BPD enters adulthood, he or she she may be hospitalized multiple times due to his or her impairment in impulse control, suicidality and quasipsychotic and dissociative symptomotology.[4,5] Patients with BPD decompensations account for 20 percent of psychiatric hospitalizations.[6] Comorbid mood disorder and substance-related disorder increase the risk of suicide, and as many as 10 percent of patients with BPD will have completed suicide by the age of 30.[4] Employment history may be wrought with multiple job losses or career changes, and interpersonal relationships are continually volatile.[6]

Fluctuations in gender identity, sexual orientation, and personal values may be common and likely stem from cognitive distortions and a fragmented sense of self.[6] Although a brief psychotic, dissociative, or mood disorder episode may recur, generally, by age 30, the patient’s affective instability and impulsivity begins to lessen.[4] However, establishing a relationship with a supportive and patient sexual partner or simply retreating to a more isolated life may contribute to earlier stabilization of disruptive emotional lability.[4]

Clinical Case, continued

Frequent and chronic feelings of depression were prevalent in Brittany’s life. Many triggers in her life instigated a depressed mood, but there were also instances when no precipitant was identified. Sometimes her depressed mood came “out of the blue.”

Additional historical information was collected during the first several psychotherapy sessions. She began reporting auditory hallucinations (hearing muffled voices calling her name) and visual hallucinations (seeing shadows) at age 12. She described one nonsuicidal self-injurious (NSSI) episode at the age of 13 when she scratched the word “alone” into her left forearm. She was subsequently very embarrassed about this as it forced her to wear long-sleeved shirts to hide it from others. She was very relieved when it healed completely, leaving no permanent scarring.

PRACTICE POINT

Treatment strategies for nonsuicidal self-injurious behavior in a psychotherapy setting. Acts of self harm may be suicidal or nonsuicidal, and both types are prevalent in BPD. It may be difficult for the psychiatrist to determine one from the other, as well as concluding the safest and least restrictive intervention to institute. The decision may be made to hospitalize the patient with nonsuicidal self harm since this behavior may be life threatening. If a patient is chronically suicidal, a psychiatrist may underestimate the severity and forego the decision to hospitalize. A decision to hospitalize may greatly affect a therapeutic relationship in a psychotherapy setting, especially if the patient disagrees with the need for hospitalization.

There are no pharmacologic interventions that are known to be specifically effective in the case of self harm. Psychotherapy remains the intervention of choice for BPD, and there is now evidence that dialectical behavioral therapy (DBT) in particular is promising.[1,7–9]

DBT relies upon principles of both cognitive behavioral therapy (CBT) and zen Buddist meditative philosophy to help patients with BPD regulate their emotions by overcoming suffering through acceptance.[4] The treatment assumes that maladaptive behaviors, including self injury, are attempts to manage intense affect. DBT strategies initially focus on reducing self harm until treatment-disruptive behavior is mastered.[4] The focus of treatment then shifts to teaching coping skills for emotional control and interpersonal relatedness, which is facilitated by an individual therapist as well as didactic skills-training groups. DBT emphasizes validation of a patient’s unbearably painful emotional experience along with acceptance that the patient is doing the best that he or she can at that moment.[4] The skills-training component focuses on mastery of four major areas: mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation.[10] Some specific therapeutic strategies include alternating between acceptance and change strategies, adding intuitive knowing to emotional experience and logical analysis, playing the devil’s advocate, exploring new points of view, turning problems into assets, extending the seriousness of the patient’s statements and advocating a middle path.[4]

Assessment of suicidality and NSSI behavior must be a top priority for the psychiatrist. Examples of NSSI behavior may include “deliberate, direct destruction of body tissue without conscious suicidal intent.”[9] The most common forms of NSSI behavior in a study by Lloyd-Richardson et al[9] included biting self, cutting/carving skin, hitting self on purpose, and burning skin.

Stanley et al[7] studied NSSI behavior, including cutting or burning, which is the most frequent reason for psychiatric visits to medical emergency departments.[7] The neurophysiology and the clinical implications of NSSI behavior are poorly understood, especially when there is no apparent suicidal intent. With a better understanding of the biological mechanisms involved in self injurious behavior (SIB), more effective pharmacologic regimens may be employed as well as accompanying psychotherapeutic interventions.[7] The NSSI group in the study by Stanley et al[7] had significantly lower levels of cerebrospinal fluid (CSF) beta-endorphin and met-enkephalin when compared with the non-NSSI group. Beta-endorphin is an opioid related to mediation of stress-induced analgesia; met-enkephalin is an opioid related to physical pain analgesia. Stanley et al[7] concluded that both opioids are thought to be involved in NSSI behavior; the severity of overall psychopathology was greater in the NSSI group. In this study, serotonergic and dopaminergic dysfunctions were not shown to have a relationship to NSSI behavior, but medications which act on the opioid system may still be implicated.

Nock et al[8] studied nonsuicidal- versus suicidal-related SIB in adolescents. Most of the adolescents assessed in this study were diagnosed with both axis I and axis II disorders, 62.9 and 67.3 percent, respectively. Overall, Nock et al[8] found that the vast majority of adolescents (70%) engaging in NSSI behavior reported a lifetime suicide attempt and more than half reported multiple attempts.[8] Some significant risk factors more closely associated with suicide attempts included a longer history of NSSI behavior, use of a greater number of methods, and absence of physical pain during NSSI behavior.[8]

Lloyd-Richardson et al[9] assessed the prevalence, associated clinical characteristics, and functions of NSSI behavior in a community sample of adolescents. This study found that the most common explanations for NSSI behavior were “to try to get a reaction from someone,” “to get control of a situation,” and “to stop bad feelings.”[9] The study found that adolescents in this community sample typically conducted the NSSI behaviors to influence behavior of others and to manage internal emotions. The psychiatrist working with patients who exhibit self harm should explore the etiology and antecedents of NSSI behavior and then institute as a goal of psychotherapy the reduction of these to the extent that is possible. The goals of the psychotherapy should also include building alternative coping strategies, increasing communication with the significant people in the patient’s life, and building on the patient’s social support system.[9]

Clinical Case, continued

Brittany reported chronic feelings of emptiness as well as worry that her loved ones would abandon her. She mentioned in a psychotherapy session an intense fear that a family member might even be taken from her by severe illness, such as influenza A (H1N1).

She had chronic thoughts of not wanting to be alive anymore and even hoped that she might be involved in a motor vehicle accident to end the “constant pain.” She had frequent thoughts of cutting herself to relieve her emotional pain, but fears of scarring prevented her from doing this.

Brittany occasionally heard muffled voices at times of maximal stress. These voices were always self deprecating, calling her fat, ugly, and stupid. Removing herself from stressful situations and being quiet helped calm the muffled voices.

Brittany: My bipolar is really out of control and none of the medications seem to work. My mood swings are all over the place and all I can think about is dying to end this misery. Doctors never help and always leave me when I need them the most. You’re the only one who really understands me.

Psychiatrist: It seems as though you’ve felt misunderstood and unable to find the help you need.

Brittany: Yes, I know I have bipolar disorder, everyone in my family has it, but my case manager asked me if I’ve ever been told I have borderline personality disorder. What do you think?

Psychiatrist: You’ve had a difficult, unpredictable childhood and because of that you’ve learned to deal with problems as best you can. However, the intense way in which you experience emotions sometimes causes you to react in ways that show others how impossible, hopeless, and painful your life seems at times.

Brittany: That may be true, but I seem to only drive people away. They are always leaving me and you probably will too. The hospital is the only place I’ve ever felt safe and cared for. If only someone who knew what they were doing could get my bipolar under control, then I wouldn’t have to live like this anymore!

Psychiatrist: Medications can be helpful; however, psychotherapy is the most important treatment for you. Would you be willing to discuss these frustrations on a weekly basis with me? Together, we could explore ways of coping that will give you the ability to better control how you experience your emotions and ultimately find the satisfaction you long for in relationships.

PRACTICE POINT

Making the diagnosis and choosing the type of psychotherapy. To arrive at an accurate diagnosis, information about presenting symptoms, past medical and psychiatric history, psychosocial history, current relationships, psychological functioning, and coping skills should be collected. Based on this information and other pertinent factors, a plan for treatment will be established.[11]

Marcinko et al[1] found that it is very important to evaluate possible comorbidity in diagnostic assessment of suicidal patients. The high prevalence of comorbid BD and BPD and some diagnostic criteria seen in both conditions present both a diagnostic and a therapeutic challenge. While pharmacotherapy is appropriate for the treatment of many psychiatric disorders, psychotherapy remains the treatment of choice for BPD. As mood stabilizers have been beneficial in the treatment of some patients with BPD, increasing attention has been given to the overlap between BPD and bipolar II disorder.[12] Although some individuals may present with BPD and comorbid BD, the majority of the evidence to date supports BPD as an independent diagnosis rather than an attenuated form of a mood disorder.[12] Furthermore, because of heterogeneity of the BPD, pharmacologic treatment has evolved to some particular dimensions of the BPD rather than the disorder in its entirety. The dimensions include affective instability, impulsive aggression, and identity disturbance. Effective medication management reduces the overall suffering of the patient and enables psychiatrists to make greater use of psychotherapeutic interventions, which are very important for BPD patients with and without BD comorbidity.

Choice of medications for patients with BPD is largely based upon the predominant axis I symptomotology, which may include anxiety, depression, hallucinations, delusions, and dissociation.4 However, it is important to consider that transient symptoms are common in the course of BPD recovery, especially in the context of often unrelenting crises. As such, pharmacologic treatment should not be disproportionately influenced by symptoms stemming primarily from the axis II diagnosis.[4] Widiger and Mullins-Sweatt[4] recommend that exploratory or supportive techniques should be utilized first in managing these symptoms. Conversely, unnecessary resistance to use of medications and relying excessively upon the psychiatrist’s own psychotherapeutic skills may extend periods of decompensation and cause more extensive suffering for the patient.[4]

The type of psychotherapy chosen is very important to the patient’s success. Psychodynamic psychotherapy is appropriate for the patient with the capacity for insight, the ability to modulate regression, and is in a stable environment.[11] For the patient with pragmatic thinking, a high degree of self control, and the need for direction and guidance, Novalis et al[11] recommends cognitive therapy. Finally, the patient with failure to progress in other types of therapies, who has real inadequacies, or who requires high levels of guidance (as in the case of an acute stressor) may be well suited for supportive psychotherapy.[11] It may be appropriate to change the type of therapy from time to time during treatment in the event that the acute needs of the patient are altered (Table 6).

Often patients with BPD will report initial, middle, and/or late insomnia. Plante et al[13] found that sleep disturbance is a common, yet poorly understood, phenomenon in BPD. Sedative-hypnotic medications were studied in patients with BPD and were used significantly more often for insomnia both as scheduled medications and “as needed” when compared to all other personality disorders. In fact, patients with BPD were four times more likely to use these medications. Plante et al[13] concluded that subjective sleep disturbance is a significant problem in BPD.[13]

Binks et al[14] completed a pharmacology study regarding treatment of BPD. BPD was found to be prevalent (2% in the general population, 20% among psychiatry in-patients) and has a significant impact on the healthcare delivery system; a complicating factor is that the patients will have frequent and recurrent crisis situations but are often nonadherent with recommended treatment options.[14] The current information available from Binks’s literature review indicates that the use of antidepressants may have a considerable positive effect in most patients.

Binks et al[15] also reviewed studies of psychological interventions and their success in patients with BPD. The definition of psychological treatments in this study included behavioral, cognitive-behavioral, psychodynamic, and psychoanalytic psychotherapies. After reviewing seven studies, Binks et al found that with DBT, some behaviors (including self harm or parasuicide) may decrease at 6 to 12 months, but there was no clear difference in hospital admissions. Another study showed a statistically significant decrease in suicidal ideation at six months for those receiving DBT.[15] Binks et al found no differences for outcomes of anxiety and depression, but those patients receiving DBT had milder symptoms than those in control groups. In summary, this review suggested that some of the problems frequently encountered by people with BPD may be amenable to psychotherapy and other behavioral treatments, especially when giving an extended course of treatment.[15]

Clinical Case, Continued

The course of treatment recommended at the end of the initial consultation was to begin psychotherapy (the treatment of choice for BPD) and initiate citalopram to address the many symptoms associated with the BPD. A slow taper of lamotrigine (Lamictal) over the course of the next several months was also planned, while continuing the full dose for the first six weeks while citalopram reached full therapeutic effect.

Over the next several weeks, Brittany agreed to adhere to medication recommendations and also engage in weekly psychotherapy sessions with her psychiatrist. Additional history revealed that Brittany had maintained a very chaotic relationship pattern throughout her early adulthood. She quickly developed feelings of attraction and dependency with multiple sexual partners. Though most partners found her sociable, supportive, and engaging, her low threshold for controlling her rage in common conflicts and disagreements typically evolved into abuse and ultimately abandonment. Moreover, her friends were frequently overwhelmed and annoyed by her intense feelings of hurt, anger, and depression. Brittany was, in turn, frequently deeply disappointed when her extreme reactions were not met with a consoling gesture.

Brittany: So I won’t be able to see you while you’re away next month?

Psychiatrist: No, but you will be able to contact the clinic in the case of an emergency. I will return for our regular session the following week.

Brittany: What if the other doctor doesn’t understand me like you do? Can I call you if I’m having a hard time?! I knew you’d eventually leave me like everyone else has! You’re a liar!

PRACTICE POINT

Abandonment issues processed from early developmental years and their persistence/significance in current relationships (including the psychiatrist in the room). According to Delgado and Songer,[5] absolute and unconditional love represents the core desire of patients with BPD. When others, including the psychiatrist, fail to embody these fantasies, affective storms may abound as they develop extreme hatred toward the imperfect person.[5] With an understanding of the patient’s early childhood experiences and family environment, the psychiatrist is able to interpret how these experiences have contributed to the development of the patient’s maladaptive coping style and its impact in relationships. A deficit in the capacity to recognize and tolerate loving and hostile feelings toward the same person simultaneously (object constancy) constitutes the foundation for his or her constant fear of abandonment. As a result, the patient persistently employs primitive or immature defense mechanisms (e.g. splitting, projection, acting out, dissociation). A therapeutic alliance represents the bedrock upon which a psychiatrist may achieve the ultimate goal of any psychotherapy: helping the patient achieve the ability to tolerate ambivalent feelings in a relationship by developing mature higher level defense mechanisms.[5]

As the treatment progresses, the therapeutic relationship between a psychiatrist and the patient with BPD can be as similarly volatile as the patients’ other significant relationships.[16] Feelings of anger or frustration toward the patient may spawn specific countertransference reactions that may include distancing, rejecting, or abandoning the patient. In addition, positive reactions may include fantasies of being the therapist who rescues or cures the patient, or romantic, sexual feelings in response to a seductive patient.[4] Proper management of these countertransference issues are best achieved through ongoing consultation with colleagues.[4] Furthermore, promoting a sense of secure attachment through frequent appointments (weekly or more frequently), communication between missed sessions or planned absences, setting limits on inappropriate or self-destructive behaviors, validation of suffering and abusive experience, helping the patient take responsibility for actions, and promotion of self reflection rather than impulsive action are key coping strategies to emphasize in the psychotherapeutic setting.[4,5]

CONCLUSION

BPD and BD symptom overlap represents a common diagnostic dilemma for psychiatrists. Carefully delineating the nature of attachments, suicidal and nonsuicidal acts, a time course of mood symptoms, role of interpersonal reactivity, and abuse history throughout childhood, adolescence, and adulthood can be especially helpful in arriving at a primary diagnosis. Chronic fears of abandonment and higher level of impulsivity, hostility, and acute suicidal threats are distinctive symptoms that can typically distinguish BPD from BD.

Aggressive pharmacologic treatment of sleep disturbance and comorbid axis I diagnoses in BPD can improve patients’ outcomes when used in combination with psychotherapy as the treatment of choice. Mood stabilizers, antidepressants, and antipsychotics have all shown efficacy in reducing the impact of common symptoms particular to the heterogeneous population with BPD, namely affective instability, impulsive aggression, and identity disturbance. Of course, careful attention must be given to the potential lethality of medications utilized in the treatment of BPD.

Choosing the appropriate modality of psychotherapy for BPD should be based on the patient’s core symptoms, cognitive abilities, need for guidance, ability to modulate regression, and level of psychological mindedness. Moreover, a psychiatrist must also be attuned to the acute needs of the patient as flexibility in changing the type of therapy in the midst of treatment may be necessary. Although DBT principles are specifically and effectively tailored to the hallmark symptoms of BPD, many other types of psychotherapy may be effective in reducing the severity of various BPD presentations. An accurate assessment of the patient’s level of functioning, mindfulness, interpersonal effectiveness, distress tolerance, emotion regulation, and strength of social support system are key elements that will lead the clinician to institute DBT, psychodynamic psychotherapy, interpersonal, CBT, and supportive psychotherapy, either individually or in combination.

Finally, building a therapeutic alliance with a patient with BPD may be a challenging task for a psychiatrist. However, understanding the common transference and countertransference reactions in a psychotherapeutic setting can equip the psychiatrist with essential foresight and knowledge to effectively facilitate the patient’s movement towards more fulfilling relationships and higher level defenses.

References
1. Marcinko D, Vuksan-Cusa B. Borderline personality disorder and bipolar disorder comorbidity in suicidal patients: diagnostic and therapeutic challenges. Psychiatr Danub. 2009;21(3):386–390.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision. Washington, DC; 2000.
3. Fiedorowicz JG, Black DW. Borderline, bipolar or both? Frame your diagnosis on the patient history. Curr Psychiatr. 2010;9 (1):21–30.
4. Widiger TA, Mullins-Sweatt SN. Personality disorders. In: Tasman A, Kay J, Lieberman J, et al, eds. Psychiatry, Third Edition. West Sussex: John Wiley & Sons, Ltd;2008:1733–1734.
5. Delgado S, Songer D. Personality disorders and behavioral disturbances. In: Gillig PM, Morrison AK, (eds.) More than Medication: Incorporating Psychotherapy into Community Psychiatry Appointments. West Chester, PA: Matrix Medical Communications; 2009:68–72.
6. National Institutes of Mental Health. Borderline Personality Disorder. 2001. http://www.nimh.
nih.gov/health/publications/borderline-personality-disorder-fact-sheet/index.shtml#4. Accessed on February 10, 2010.
7. Stanley B, Sher L, Wilson S, et al. Non-suicidal self-injurious behavior, endogenous opioids and monoamine neurotransmitters. J Affect Disord. 2009 Nov 24. [Epub ahead of print]
8. Nock MK, Joiner TE Jr, Gordon KH, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006;144(1),65–72.
9. Lloyd-Richardson EE, Perrine N, Dierker L, Kelley ML. Characteristics and functions of non-suicidal self-injury in a community sample of adolescents. Psychol Med. 2007;37(8):1183–1192.
10. Huffman, JC, Stern TA, Harley RM, Lundy NA. The use of DBT skills in the treatment of difficult patients in the general hospital. Psychosomatics. 2003;44: 421–429.
11. Novalis PN, Rojcewicz SJ Jr, Peele R. Clinical Manual of Supportive Psychotherapy, First Edition. Washington, DC: American Psychiatric Press, Inc.;1993.
12. American Psychiatric Association. Practice Guidelines for the Treatment of Patients with Borderline Personality Disorder: Guideline Watch. Washington, DC; 2005. DOI:10:1176/appi.books.
9780890423363.148718. Accessed on February 10, 2010.
13. Plante DT, Zanarini MC, Frankenburg FR, Fitzmaurice GM. Sedative-hypnotic use in patients with borderline personality disorder and axis II comparison subjects. J Pers Disord. 2009. 23(6):563–571.
14. Binks CA, Fenton M, McCarthy L, et al. Pharmacological interventions for people with borderline personality disorder. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD005653.
15. Binks CA, Fenton M, McCarthy L, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD005652.
16. Gunderson JG. Borderline Personality Disorder: A Clinical Guide. Washington, DC: American Psychiatric Press;2001.

Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Primary Care Clinic at Wright-Patterson Air Force Base. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.

Psychiatry (Edgemont) 2009;6(10):16–20

by Randy A. Sansone, MD, and Lori A. Sansone, MD

Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Primary Care Clinic at Wright-Patterson Air Force Base. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.

Psychiatry (Edgemont) 2009;6(10):16–20

Financial Disclosures

The authors have no conflicts of interest relevant to the content of this article.

Abstract

Borderline personality disorder is characteristically associated with a broad variety of psychiatric symptoms and aberrant behaviors. In this edition of The Interface, we discuss the infrequently examined association between borderline personality disorder and criminality. According to our review of the literature, in comparison with the rates of borderline personality disorder encountered in the general population, borderline personality disorder is over-represented in most studies of inmates. At the same time, there is considerable variation in the reported rates of this Axis II disorder in prison populations, which may be attributed to the methodologies of and populations in the various studies. Overall, female criminals appear to exhibit higher rates of borderline personality disorder, and it is oftentimes associated with a history of childhood sexual abuse, perpetration of impulsive and violent crimes, comorbid antisocial traits, and incarceration for domestic violence.

Key words

borderline personality disorder, BPD, criminality, inmate

Introduction

The year is 1992. The movie is, “Single White Female.” The storyline entails protagonist, Hedra Carlson (Jennifer Jason Leigh), who appears to suffer from borderline personality disorder (BPD). She attempts to copy the appearance and characteristics of sequential roommates in a guilty attempt to virtually recreate her dead twin sister, who drowned during a family picnic. As the movie unfolds, the viewer is introduced to the fact that a previous roommate did not “work out,” so Hedy killed her.

Clinicians have long been aware of associations between mental illness and criminality. Indeed, according to a recent report by 57 independent monitoring boards of prisons in the United Kingdom (UK), 90 percent of inmates have at least one diagnosable mental disorder.[1] While a number of Axis I disorders, such as bipolar disorder, are clearly represented in prison populations, there are also various Axis II disorders among the incarcerated. Importantly, these Axis II disorders extend beyond antisocial personality disorder—the traditional prison “personality.” In this edition of The Interface, we focus on one specific personality disorder, BPD, and its associations with criminality.
The Prevalence of BPD in Prison Populations

Studies indicating an over-representation of BPD in prison populations. The prevalence of BPD in the general US population ranges between two percent with rates reportedly greater in women (i.e., the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision)[2] and six percent with rates approximately equal between the sexes (the recent findings of Grant et al[3]). In comparison, we found that there is substantial empirical evidence that BPD is over-represented in prison populations. Although not intended as a full review of the literature, the following studies provide a general sense of the high prevalence of BPD in various prison populations.

In an interview-based study, Jordan et al[4] examined female felons (N=805) who were newly admitted to a North Carolina prison. They found that 28 percent of these inmates met the criteria for BPD. In a Spanish study by Riesco et al,[5] researchers examined 56 male prisoners with a structured personality disorder assessment and determined that 41 percent suffered from BPD. In a study comparing the diagnostic efficacy of two measures of personality disorders, Davison, Leese, and Taylor[6] examined male prisoners in two UK prisons. On one measure, the prevalence of BPD in these populations was 45.7 percent, and on the second, 47.4 percent. Among imprisoned men convicted of sexual offenses, Dunsieth et al[7] found that 28.3 percent of 113 participants met the criteria for BPD based on structured clinical interviews. Using a structured interview for diagnosis, Black et al[8] examined the rate of BPD in newly admitted prisoners to the Iowa Department of Corrections. In this sample, 29.5 percent met the criteria for BPD; the rate among women was twice that encountered in men. Collectively, these studies—all using specific measures for personality disorder assessment—suggest that approximately 25 to 50 percent of prisoners suffer from BPD.
There are two studies of offenders in which researchers examined rates of BPD in a specific population—those in prison substance abuse treatment programs. In the first, Zlotnick et al[9] systematically examined 272 offenders in these treatment programs and found that 8.3 percent of male and 20.7 percent of female participants suffered from BPD. In the second study of 280 participants, using a structured interview, Grella et al[10] found that 13 percent of offenders in prison substance abuse treatment programs evidenced BPD.

Studies with differing rates depending on gender. Some studies have found differing rates of BPD in prison populations based on gender, with rates among men approximating the general population and rates among women being far higher. For example, using psychological testing, Burke examined 8,574 male and 894 female prisoners and determined that the prevalence of BPD traits was 5.3 percent and 11.5 percent, respectively.[11] In a German study, using structured clinical interviews, von Schonfeld et al[12] examined the rates of BPD among both male (n=76) and female (n=63) prisoners; the overall rate of BPD in this population was 22.3 percent. However, men demonstrated rates comparable to the general population (5.3%), whereas women had exceedingly higher rates (42.9%).

Studies refuting an over-representation of BPD in prison populations. We were able to locate two studies that found rates of BPD in prison populations that were comparable to community samples. In the first, a study of Cluster B disorders, researchers initially screened 802 female inmates.[13] In the second phase of the study, all Cluster-B-positive patients (261) underwent a structured interview. Of the initial 802 subjects, ultimately only 5.2 percent evidenced BPD; both antisocial and paranoid personality disorders exceeded this percentage. While these data appear to refute the preceding findings, note that the initial sample of 802 participants did not undergo structured interviews for personality disorder assessment. It is possible that the screening measure in this study underdetected the rates of BPD in this sample.

In the second study, researchers retrospectively examined diagnoses of patients admitted to forensic psychiatry units in the UK between 1988 and 1994.[14] Of these admissions, only 5.7 percent met the criteria for BPD. Again, the methodology may have influenced the percentage of patients with BPD, based upon the following: (1) the historical nature of the data, which is potentially limited by the individuals who unsystematically recorded these data; and (2) the possibility that patients with personality-disorders-only are under-represented in bonafide forensic facilities (i.e., in these settings, patients with Axis I disorders, such as bipolar, schizophrenic, and dissociative identity disorders, may be predominant).

Conclusions. We may draw several general conclusions from the preceding data. First, a substantial majority of studies in this area support the impression of higher rates of BPD in prison populations than in community samples, with rates generally ranging between 25 and 50 percent. Second, in studies that simultaneously compared men and women, rates among women appear to be consistently higher than in men. Finally, while two studies found rates of BPD similar to rates in community samples, the respective methodologies may explain these uncharacteristically low rates.

Factors Related to a Heightened Likelihood of BPD in Inmates

A number of factors appear to be associated with a greater likelihood of the diagnosis of BPD in a given inmate. In this section, we will review these factors.

Being female. It appears that incarcerated women harbor higher rates of BPD than incarcerated men.[9,11,12,14] Whether this is genuine or related to a subtle bias in the measures for this disorder is unknown.

Childhood sexual abuse. Sexual abuse in childhood has long been known to be a general but nonspecific contributory factor to the development of BPD in adulthood. The data in prison populations appear to mirror this literature. For example, Christopher, Lutz-Zois, and Reinhardt[15] examined 142 female inmates to examine contributory variables to BPD. In this sample, 61 participants were sex offenders and 81 were not. As expected, sexual abuse in childhood was associated with the diagnosis of BPD. In addition, participants in the sex-offender subsample were significantly more likely to report such histories.

Violent offenses. Borderline personality is associated with longstanding impulsivity and affective instability, including rage reactions. Therefore, one would suspect that more impulsive and violent offenders might be diagnosed with this disorder. Data seem to support these impressions.[16,17] For example, Logan and Blackburn[18] examined 95 women who had been incarcerated for violent offenses. Compared with women who had perpetrated minor violence, those with incarcerations related to major violence were four times more likely to be diagnosed with BPD. In keeping with these findings, Hernandez-Avila et al[19] examined 370 alcohol/substance-dependent patients for criminal behavior and found that the diagnosis of BPD was associated with a greater number of pretreatment violent crimes.

While few studies have systematically examined the prevalence of BPD in those who commit homicide, Yarvis[20] reported that BPD was one of the more common psychiatric diagnoses in a series of 100 murderers. In a British study of 90 men who were incarcerated for the murder of their female partner, Dixon et al[21] found that 49 percent had borderline personality characteristics. In a German study, Hill et al[22] examined individuals convicted of one-time sexual homicides and found that BPD was well represented. In contrast to these studies, in a French study, Pera and Dailliet[23] found that only eight percent of 99 murderers suffered from BPD.

A number of authors have speculated about associations between variations of BPD (i.e., subtypes) and murderous acts. For example, Ansevics and Doweiko[24] present the perspective that serial murderers represent a subtype of BPD, highlighted by manipulativeness. Cartwright argues that rage-based murders are related to a particular subtype of BPD characterized by elements of over-control.[25] Finally, Papazian[26] discusses the role of BPD in the serial killer. In summary, while not definitive at this juncture, the majority of current data and impressions indicate an association between BPD and the impulsive, rage-fueled murder.

Antisocial personality traits/disorder. Comorbid antisocial personality features may be associated with a heightened risk of criminality in individuals with BPD. In this regard, Howard et al[27]compared those with mixed antisocial and borderline personality traits to individuals with various types of other personality dysfunction, including antisocial or borderline personality only. They found that the mixed cohort demonstrated higher trait anger, trait impulsivity, and aggression scores, resulting in an overall higher score on psychopathy.

Researchers have also compared criminals with antisocial versus borderline personality disorders and found some differences in the nature of their crimes. For example, de Barros et al[28] found that while antisocial individuals tend to engage in more property crimes, borderline individuals tend to exhibit more episodes of aggression and physical violence. The authors concluded that criminals with pure antisocial personality are more calculating and exhibit more detailed planning, whereas those with BPD experience more impulsive and explosive episodes of violence. Again, one would assume that combining the two disorders would result in a very criminally combustible outcome.
Domestic violence. An association between BPD and partner violence has peppered the empirical literature over the past decade or so. For example, compared to nonbatterers, Else et al[29] described a small sample of male batterers as evidencing comparatively higher scores on borderline and antisocial measures. Tweed and Dutton30 examined subtypes of male batterers and described a Type 2 profile with borderline personality characteristics. In a sample of 94 male batterers, Meyer[31] found evidence of chronic personality dysfunction, again primarily with antisocial and borderline elements. Lawson et al[32] examined 91 male batterers and identified three subgroups: (1) nonpathological, (2) borderline/dysphoric, and (3) antisocial. In developing a psychometric typology of male batterers in the UK, Johnson et al[33] identified four types of offenders, one of which was BPD. In a similar vein, Chambers and Wilson[34] examined 93 male batterers and found evidence for two clusters, one of which was BPD. Dutton[35] summarized this literature in 2007 by indicating that many male batterers suffer from borderline personality as well as chronic symptoms of trauma.

Interestingly, the continual diagnostic appearance of BPD in male batterers is echoed in the literature on female batterers, as well. In this regard, Chavez[36] examined both male and female batterers and found a higher prevalence of borderline personality characteristics in both when compared to nonbatterers. Stuart et al[37] examined female batterers who were arrested for domestic violence and found that 27 percent met the criteria for BPD.

Conclusion

According to the findings of the majority of studies in this area, compared to rates expected in the community, BPD is over-represented in prison populations. This finding may be particularly evident among female prisoners. Rates vary, depending on the methodology, but generally appear to be in the range of 25 to 50 percent. Factors that may be associated with the presence of BPD among criminals include being female, having a history of childhood sexual abuse, committing an impulsive and violent crime (e.g., murder), having antisocial personality disorder traits, and perpetrating domestic violence. Given this association, clinicians in both mental health and primary care settings need to be aware of the possibilities of such histories in their patients with BPD.

References

1. BBC News.Too many mentally ill in jails. http://news.bbc.co.uk/2/hi/
uk_news/7867398.stm. Accessed on 2/4/09.
2. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Press Inc.;2000.
3. Grant BF, Chou SP, Goldstein RB, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2008;69:533–545.
4. Jordan K, Schlenger WE, Fairbank JA, Caddell JM. Prevalence of psychiatric disorders among incarcerated women. Arch Gen Psychiatry. 1996;53:513–519.
5. Riesco Y, Perez Urdaniz A, Rubio V, et al. The evaluation of personality disorders among inmates by IPDE and MMPI. Actas Luso Exp Neurol Psiquiatr Cienc Afines. 1998;26:151–154.
6. Davison S, Leese M, Taylor PJ. Examination of the screening properties of the Personality Diagnostic Questionnaire 4+ (PDQ-4+) in a prison population. J Personal Disord. 2001;15:180–194.
7. Dunsieth NW, Nelson EB, Brusman-Lovins LA, et al. Psychiatric and legal features of 113 men convicted of sexual crimes. J Clin Psychiatry. 2004;65:293–300.
8. Black DW, Gunter T, Allen J, et al. Borderline personality disorder in male and female offenders newly committed to prison. Compr Psychiatry. 2007;48:400–405.
9. Zlotnick C, Clarke JG, Friedmann PD, et al. Gender differences in comorbid disorders among offenders in prison substance abuse treatment programs. Behav Sci Law. 2008;26:403–412.
10. Grella CE, Greenwell L, Prendergast M, et al. Diagnostic profiles of offenders in substance abuse treatment programs. Behav Sci Law. 2008;26:369–388.
11. Burke JM. Male borderline personality disorder with comorbid disorders as contrasted to females with comorbid disorders in a correctional setting. Diss Abstr Int. 2005;65:4885B.
12. von Schonfeld C-E, Schneider F, Schroder T, et al. Prevalence of psychiatric disorders, psychopathology, and the need for treatment in female and male prisoners. Nervenarzt. 2006;77:830–841.
13. Warren JI, Burnett M, South SC, et al. Personality disorders and violence among female prison inmates. J Am Acad Psychiatry Law. 2002;30:502–509.
14. Coid J, Kahtan N, Gault S, Jarman B. Patients with personality disorder admitted to secure forensic psychiatry services. Br J Psychiatry. 1999;175:528–536.
15. Christopher K, Lutz-Zois CJ, Reinhardt AR. Female sexual-offenders: personality pathology as a mediator of the relationship between childhood sexual abuse history and sexual abuse perpetration against others. Child Abuse Negl. 2007;31:871–883.
16. Ullrich S, Marneros A. Dimensions of personality disorders in offenders. Crim Behav Ment Health. 2004;14:202–213.
17. Coid J, Kahtan N, Gault S, Jarman B. Patients with personality disorder admitted to secure forensic psychiatry services. Br J Psychiatry. 1999;175:528–536.
18. Logan C, Blackburn R. Mental disorder in violent women in secure settings: potential relevance to risk for future violence. Int J Law Psychiatry. 2009;32:31–38.
19. Hernandez-Avila CA, Burleson JA, Poling J, et al. Personality and substance use disorders as predictors of criminality. Compr Psychiatry. 2000;41:276–283.
20. Yarvis RM. Axis I and Axis II diagnostic parameters of homicide. Bull Am Acad Psychiatry Law. 1990;18:249–269.
21. Dixon L, Hamilton-Giachritsis C, Browne K. Classifying partner femicide. J Interpers Violence. 2008;23:74–93.
22. Hill A, Habermann N, Berner W, Briken P. Psychiatric disorders in single and multiple sexual murderers. Psychopathology. 2007;40:22–28.
23. Pera SB, Dailliet A. Homicide by mentally ill: clinical and criminological analysis. Encephale. 2005;31:539–549.
24. Ansevics NL, Doweiko HE. Serial murderers: early proposed developmental model and typology. Psychotherapy Priv Pract. 1991;9:107–122.
25. Cartwright D. The role of psychopathology and personality in rage-type homicide: a review. S Afr J Psychol. 2001;31:12–19.
26. Papazian LM. Literature review on the personalities and patterns of serial killers. Diss Abstr Int. 2001;61:6144B.
27. Howard RC, Huband N, Duggan C, Mannion A. Exploring the link between personality disorder and criminality in a community sample. J Personal Disord. 2008;22:589–603.
28. de Barros DM, de Padua Serafim A. Association between personality disorder and violent behavior pattern. Forensic Sci Int. 2008;179:19–22.
29. Else LT, Wonderlich SA, Beatty WW, et al. Personality characteristics of men who physically abuse women. Hosp Community Psychiatry. 1993;44:54–58.
30. Tweed RG, Dutton DG. A comparison of impulsive and instrumental subgroups of batterers. Violence Vict. 1998;13:217–230.
31. Meyer S-L. Prevalence and characteristics of sexual aggression in court-mandated batterers. Diss Abstr Int. 2000;60:3573B.
32. Lawson DM, Weber D, Beckner HM, et al. Men who use violence: intimate violence versus non-intimate violence profiles. Violence Vict. 2003;18:259–277.
33. Johnson R, Gilchrist E, Beech AR, et al. A psychometric typology of U.K. domestic violence offenders. J Interpers Violence. 2006;21:1270–1285.
34. Chambers AL, Wilson MN. Assessing male batterers with the Personality Assessment Inventory. J Pers Assess. 2007;88:57–65.
35. Dutton DG. The Abusive Personality: Violence and Control in Intimate Relationships. New York: Guilford Press;2007.
36. Chavez LJ. Analysis of borderline personality organization among female and male domestic violence batterers. Diss Abstr Int. 2005;65:6039B.
37. Stuart GL, Moore TM, Gordon KC, et al. Psychopathology in women arrested for domestic violence. J Interpers Violence. 2006;21:376–389.

Dr. Salzbrenner is USN at Naval Medical Center Portsmouth; and Ms. Conaway is from the Virginia College of Osteopathic Medicine.

Professor of Psychiatry, Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio

Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Primary Care Clinic at Wright-Patterson Air Force Base. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.

Psychiatry (Edgemont) 2008;5(8):18–21

Abstract
Borderline personality is an Axis II disorder that has historically encompassed a number of different psychiatric symptoms. In empirical studies, these multiple psychiatric symptoms appear to manifest as numerous comorbid Axis I and II diagnoses. In echoing these findings in primary care settings, individuals with borderline personality exhibit prolific somatic symptoms. Rather than the type of symptom, are the number of symptoms suggestive of this disorder, such that proliferative psychiatric or medical symptoms are diagnostically relevant? We discuss these issues and conclude that the number of symptoms is an unacknowledged but important diagnostic feature in borderline personality disorder.

Introduction
Borderline personality is a dramatic Axis II disorder that affects anywhere from 2 to 10 percent of the general population.[1,2] In primary care settings, the prevalence rate is around seven percent,[3] whereas in psychiatric settings, the rates are considerably higher, up to 50 percent among inpatients.[4] These data indicate that borderline personality disorder (BPD) is a relatively common psychiatric phenomenon—one that emerges frequently in both psychiatric and primary care settings. From a historical perspective, the diagnostic formulation of this disorder has been challenging. Specifically, various clinicians and investigators have attributed differing clinical characteristics to patients with BPD, which has contributed to the general diagnostic angst. In this article, we offer a possible explanation.

The Historical Diagnosis of BPD
Understandably, clinicians have historically diagnosed patients with BPD in terms of specific psychological patterns and symptoms. However, the symptom constellations associated with BPD have varied considerably over time. For example, Stern[5] identified 10 clinical symptoms associated with BPD, including narcissism, hypersensitivity, masochism, and disturbances in reality testing. Deutsch[6] highlighted BPD symptomatology in the context of interpersonal functioning. Specifically, she noted that while individuals with BPD appear to function normally in brief social interactions (as if they were normal), they exhibit an underlying pathological style of relatedness with others. Schmideberg[7] described nine specific features of BPD, including the inability to tolerate routines, low motivation for treatment, chaotic lifestyle patterns, and difficulties in establishing emotional contact with others. Hoch and Polatin[8] described the clinical triad of pan-anxiety, pan-sexuality, and pan-neurosis. Knight[9] emphasized the presence of multiple neurotic symptoms, lack of achievement, and psychological vacillation between neurotic and psychotic states. Indeed, all of these varied descriptive features certainly capture many of the clinical facets of individuals with BPD.

In more recent times, the diagnosis of BPD has continued to rely on the presence of particular symptoms or symptom clusters. For example, Kernberg[10] developed a diagnostic approach to BPD entitled the “Presumptive Diagnostic Elements,” which highlights the symptoms of pervasive anxiety, multiple neuroses, impulsivity, and addictions. Kolb and Gunderson[11] described five fundamental characteristics of patients with BPD, which are quasipsychotic phenomena (i.e., fleeting losses of reality), impulsivity (i.e., chronic self-regulation difficulties, longstanding self-destructive behavior), a superficially intact social façade, chaotic interpersonal relationships, and chronic affective disturbance. These clinical characteristics subsequently became the cornerstones for the Diagnostic Interview for Borderlines (original version).[11]
The focus on diagnosis through specific symptom assessment has also culminated in the current criteria for BPD, which were initially described in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (published in 1980).[12] (The two prior versions of the DSM did not contain the diagnosis of BPD at all.) The most recent criteria for the disorder, which are described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR),[13] are (a) frantic efforts to avoid abandonment; (b) a history of unstable and intense relationships with others; (c) identity disturbance; (d) impulsivity in at least two functional areas, such as spending, sex, substance use, eating, or driving; (e) recurrent suicidal threats or behaviors as well as self-mutilation; (f) affective instability with marked reactivity of mood; (g) chronic feelings of emptiness; (h) inappropriate and intense anger or difficulty controlling anger; and (i) transient stress-induced paranoid ideation or severe dissociative symptoms. Five of the preceding nine criteria are required for diagnosis.

We wish to underscore that the previous clinicians and investigators have accurately described a number of clinical features that may be attributed to BPD. Yet, with the exception of the DSM criteria, there appears to be only modest overlap among the historical criteria sets. Is this ongoing declaration of diverse symptoms due to mistaken clinical observations and/or conclusions? Or could it represent the fact that patients with BPD have proliferative symptoms? We suspect the latter explanation. In other words, in addition to the type of symptoms commonly encountered in BPD, which respected authorities might debate, it appears that the number of symptoms may be an essential diagnostic indicator, as well.

Multiple Psychiatric Symptoms in BPD
Note that many of the preceding authorities in the field have alluded to the presence of a high number of diverse clinical symptoms in BPD, without actually highlighting this prominent and unusual psychiatric characteristic, itself. For example, Hoch and Polatin,[8] Knight,[9] and Kernberg[10] all refer to multiple neurotic symptoms. The criteria in the Diagnostic Interview for Borderlines includes a section on impulsivity, which explores multiple self-regulation and self-harm behaviors.[11] Finally, the contemporary DSM-IV-TR criteria refer to impulsivity “in at least two areas,” suggesting the presence of multiple diverse symptoms.[13] However, are there any research data that support these impressions?

Multiple Axis I disorders: The evidence. Several studies document the presence of multiple Axis I disorders in patients with BPD. The first was undertaken by Zanarini and colleagues,[14] who examined the prevalence of Axis I comorbidity among 379 patients with BPD, compared with 125 patients with other personality disorders. These authors concluded that complex Axis I comorbidity is strongly predictive of the BPD diagnosis.

Zimmerman and Mattia[15] examined comorbidity patterns among 409 patients using semistructured diagnostic interviews. The BPD subsample was diagnosed with significantly more Axis I diagnoses than the non-BPD subsample. In this study, the authors found that the BPD subsample was twice as likely to receive diagnoses of three or more current Axis I disorders and nearly four times as likely to receive diagnoses of four or more Axis I disorders. In this cohort, a high level of Axis I comorbidity was observed for both current and lifetime diagnoses.

In a sample of outpatients being seen in a university-based resident psychotherapy clinic, we retrospectively examined Axis I comorbidity among 61 patients with BPD, 128 patients with another personality disorder, and 91 patients without any personality disorder.[16] The BPD subgroup had significantly more Axis I diagnoses than either of the comparison groups.

Finally, in a study of patients from “everyday clinical practice,” Conklin and Westen17 compared those with BPD to patients diagnosed with dysthymia and no personality disorder. As predicted, those with BPD evidenced a much broader array and frequency of Axis I psychiatric comorbidity than either of the comparison groups.

Axis II disorders: The evidence. We are only aware of one study that has examined Axis II comorbidity in BPD in relationship to a comparison group. In this study, Zanarini and colleagues[18] examined the prevalence of comorbid Axis II disorders among those with BPD versus individuals with other types of personality disorders (i.e., any other personality disorder but BPD). The BPD subgroup exhibited an average of 2.65 comorbid Axis II diagnoses per participant whereas the non-BPD Axis II subgroup had 1.32 comorbid Axis II diagnoses per participant. In other words, the BPD cohort had twice as many comorbid personality disorders as the non-BPD cohort.

Multiple Somatic Symptoms in BPD
The observed disproportionate comorbid psychiatric symptomatology encountered in BPD appears to be echoed with regard to somatic symptoms among these patients, as well. For example, we initially examined this relationship in a sample of 120 outpatients in an internal medicine setting.[19] The correlation coefficient between borderline personality symptomatology as measured by the Personality Diagnostic Questionnaire-Revised,[20] self-report version of the diagnostic criteria for BPD that are listed in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised,[21] and somatic preoccupation as measured by the Bradford Somatic Inventory,[22] was r=0.43 (p<0.01). We recently repeated this methodology using two measures of BPD.[23] In this subsequent study of 116 internal medicine outpatients, we found even higher correlations (i.e., r=0.53, r=0.58) between each measure of BPD and somatic preoccupation (i.e., the number of endorsed somatic symptoms) according to the Bradford Somatic Inventory.

Along similar lines, Frankenburg and Zanarini[24] compared borderline patients with active symptomatology to remitted patients. These investigators found that, compared to unremitted patients, those with remitted Axis II symptoms were significantly less likely to have a “syndrome-like” medical condition such as chronic fatigue, fibromyalgia, or temporomandibular joint syndrome.

Given the empirically confirmed higher rate of somatic symptoms that are encountered in patients with BPD, one would expect this phenomenon to be reflected in higher rates of healthcare utilization. Indeed, compared to non-BPD patients, we have empirically confirmed significantly greater healthcare utilization in medical settings by patients with BPD.[25,26] In one study of 194 female family medicine outpatients, we found that scores on the measure for BPD were significantly related to the number of facility contacts (i.e., physician visits and telephone calls) as well as the number of prescriptions.[25] In a second study, we retrospectively examined the healthcare utilization patterns of 116 female family medicine patients during the preceding year.[26] The investigator who was assigned to review the medical records was blind to participants’ Axis II status. As predicted, compared with non-BPD participants, those with BPD had a significantly greater number of office visits and ongoing prescriptions.

BPD Diagnosis: A Refinement in Approach
BPD has historically struggled to attain a consistent diagnostic identity. Along the way, opponents have challenged the reliability and validity of various criteria sets in this search for diagnostic legitimacy. Maybe the historic difficulty in ascribing a distinct and valid compilation of symptoms to BPD is that the disorder is, by nature, a proliferative one—both in terms of psychological and somatic symptoms. It could be that our current DSM criteria capture the psychiatric symptoms most commonly encountered in these individuals, but neglect the genuine clinical nature of the disorder—the propensity to generate multiple symptoms, either psychiatric or somatic. Perhaps this characteristic should be an additional diagnostic criterion, or at the very least a clinical descriptor, for the disorder in the DSM. Such clarification might result in the diagnostic capture of a subset of individuals with BPD who do not present with the most commonplace symptoms noted in the DSM (e.g., somatic variations). From both a clinical and empirical perspective, proliferative symptoms appear to uniquely distinguish this challenging disorder from any other psychiatric disorder in the DSM.

References
1. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Press Inc., 1994.
2. Stone MH. Borderline personality disorder. In: Michels R, Cavenar JO (eds). Psychiatry, Second Edition. Philadelphia: Lippincott, 1986:1–15.
3. Gross R, Olfson M, Gameroff M, et al. Borderline personality disorder in primary care. Arch Intern Med. 2002;162:53–60.
4. Sansone RA, Sansone LA. Borderline personality: a psychiatric overview. In: Sansone RA, Sansone LA (eds). Borderline Personality in the Medical Setting: Unmasking and Managing the Difficult Patient. New York: Nova Science Publishers, 2007:5.
5. Stern A. Borderline group of neuroses. Psychoanal Q. 1938;7:467–489.
6. Deutsch H. Some forms of emotional disturbance and their relation to schizophrenia. Psychoanal Q. 1942;11:301–321.
7. Schmideberg M. The treatment of psychopaths and borderline patients. Am J Psychother. 1947;1:45–70.
8. Hoch P, Polatin P. Pseudoneurotic forms of schizophrenia. Psychiatr Q. 1949;23:248–276.
9. Knight RP. Borderline states. Bull Menninger Clin. 1953;17:1–12.
10. Kernberg O. Borderline personality organization. J Am Psychoanal Assoc. 1967;15:641–685.
11. Kolb JE, Gunderson JG. Diagnosing borderline patients with a semi-structured interview. Arch Gen Psychiatry. 1980;37:37–41.
12. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, Third Edition. Washington, DC: American Psychiatric Press Inc., 1980.
13. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Press Inc., 2000.
14. Zanarini MC, Frankenburg FR, Dubo ED, et al. Axis I comorbidity of borderline personality disorder. Am J Psychiatry. 1998;155:1733–1739.
15. Zimmerman M, Mattia JI. Axis I diagnostic comorbidity and borderline personality disorder. Compr Psychiatry. 1999;40:245–252.
16. Sansone RA, Rytwinski D, Gaither GA. Borderline personality and psychotropic medication prescription in an outpatient psychiatry clinic. Compr Psychiatry. 2003;44:454–458.
17. Conklin CZ, Westen D. Borderline personality disorder in clinical practice. Am J Psychiatry. 2005;162:867–875.
18. Zanarini MC, Frankenburg FR, Dubo ED, et al. Axis II comorbidity of borderline personality disorder. Compr Psychiatry. 1998;39:296–302.
19. Sansone RA, Wiederman MW, Sansone LA. Adult somatic preoccupation and its relationship to childhood trauma. Violence Vict. 2001;16:39–47.
20. Hyler SE, Rieder RO. Personality Diagnostic Questionnaire-Revised (PDQ-R). New York: New York State Psychiatric Institute, 1987.
21. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Washington, DC: American Psychiatric Press, Inc., 1987.
22. Mumford DB, Bavington JT, Bhatnagar KS, et al. The Bradford Somatic Inventory. A multi-ethnic inventory of somatic symptoms reported by anxious and depressed patients in Britain and the Indo-Pakistan sub-continent. Br J Psychiatry. 1991;158:379–386.
23. Sansone RA, Tahir NA, Buckner VR, Wiederman MW. The relationship between borderline personality symptomatology and somatic preoccupation among internal medicine outpatients. Prim Care Companion. 2008:(in press).
24. Frankenburg FR, Zanarini MC. The association between borderline personality disorder and chronic medical illnesses, poor health-related lifestyle choices, and costly forms of health care utilization. J Clin Psychiatry. 2004;65:1660–1665.
25. Sansone RA, Sansone LA, Wiederman MW. Borderline personality disorder and health care utilization in a primary care setting. South Med J. 1996;89:1162–1165.
26. Sansone RA, Wiederman MW, Sansone LA. Borderline personality symptomatology, experience of multiple types of traumas, and health care utilization among women in a primary care setting. J Clin Psychiatry. 1998;59:108–111.