Out on the Border, Walking the Line*

Abstract & Commentary

Synopsis: Patients with borderline personality disorder are common in primary care practices, but many are invisible to physicians.

Source: Gross R, et al. Arch Intern Med. 2002;162:53-60.

Borderline personality disorder (BPD) is "a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts."1 At least 5 of the following must be present: 1) frantic efforts to avoid real or imagined abandonment; 2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation; 3) identity disturbance: markedly and persistently unstable self-image or sense of self; 4) impulsivity in at least 2 areas that are potentially self-damaging; 5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior; 6) affective instability due to a marked reactivity of mood; 7) chronic feelings of emptiness; 8) inappropriate, intense anger or difficulty controlling anger; and 9) transient, stress-related paranoid ideation or severe disassociative symptoms. Some days, it seems that every other patient fits this description, but just how common is this disorder in primary care?

Gross and colleagues set out to answer this question and 3 others: are BPD patients functionally impaired?; how do they compare with patients who have other mental illnesses?; and are they clinically recognized and treated?

Drawing from a predominantly older (average age 53.5), Hispanic (69.3%), and poor (85.3% with annual income less than $12,000) population attending their general medicine academic practice in New York City, they called 218 patients. Study participants were administered several surveys. One measured the patients’ perceptions of their physical and mental health. Others were sections from the Patient Health Questionnaire, the self-report version of the Primary Care Evaluation of Mental Disorders, the Mini-International Neuropsychiatric Interview to evaluate psychotic symptoms, the Sheehan Disability Scale, and a sociodemographic questionnaire. These surveys were supplemented by a structured diagnostic interview, and the Medical Outcomes 36-item Short-Form Health Survey (SF-36), the Social Adaptation Self-evaluation Scale (SASS), and the Social Adjustment Scale-Self-Report (SAS-SR). The physicians seeing these patients completed an encounter form, which rated their perceptions of the patients’ physical and mental health.

The patients were divided into 3 groups: those with BPD and 2 control groups, those with a different psychiatric diagnosis (DPD), and those without any psychiatric diagnosis. The group of patients with other mental disorders was included because BPD patients have high rates of comorbid mental disorders. Fourteen patients (6.4%) met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DMS-IV) criteria for BPD, 51 had other psychiatric disorders, and 140 were control subjects. The BPD patients were demographically similar to the comparison and control patients, except for gender. There were more females in the DPD group (90.2%) than in the BPD (78.6%) and control groups (71.4%).

As expected, the BPD (21.4%) and DPD (19.6%) groups had more suicidal ideation than the control group (5.7%). The BPD group (71.4%) had more psychotic symptoms than the other 2 groups (39.2 and 10.0%, respectively), and, by definition, the BPD group had more BPD symptoms. Interestingly, 21.4% of the BPD group met criteria for bipolar disorder; none of the patients with any other psychiatric disorder did.

Are BPD patients functionally impaired and how do they compare with patients who have other mental illnesses? Yes, and essentially the same. They and the DPD group had about twice as much reported poor or fair emotional health as compared to controls (78.6%, 76.5%, and 35.0%, respectively). The 2 groups also had more reported poor or fair physical health (71.4%, 82.4%, and 59.3%) and disability (57.1%, 60.8%, and 25.7%). Additionally, their SF-36 scores for mental health were worse than the control group. However, the SF-36 scores for physical health were not significantly different between the 3 groups. The BPD and DPD groups scored worse that the control group on both the SAS-SR and SASS scales.

Are they clinically recognized and treated? Not really. The physicians identified 54.5% of BPD patients, 55.0% of the DPD patients, and 31.9% of those without any psychiatric diagnosis with poor or fair current emotional health. They rated 54.5% of the BPD patients, 75.6% of the DPD patients, and 35.6% of the presumably normal controls with "active or ongoing emotional or mental problems." Approximately one half of the BPD and DPD patients received mental health care in the preceding year, compared to less than 1 in 10 of the control group.

Comment by Allan J. Wilke, MD

BPD first officially appeared in the DSM in 1980; the borderline referred to that no-man’s land between neurosis and schizophrenia, although the DSM does not currently support this implication.2 It is present in the general population at 1-2% with more women than men affected, and in clinical settings, it is the most commonly seen personality disorder. Not sure what borderline personality looks like? Tonight, after work, go to your neighborhood video rental store and pick up Fatal Attraction, Looking for Mr. Goodbar, and Play Misty for Me.3

Is there any reason to question the results? The study population was poor Hispanic, which may not describe the population you serve. However, the disorder is present in cultures all around the globe.4 We may fault the physicians for overcalling poor mental health in the control group, but, then again, 10% of these "normals" reported delusions or hallucinations in the recent past.

In October 2001, the American Psychiatric Association published the Practice Guideline for the Treatment of Patients with Borderline Personality Disorder.5 The treatment is a minimum of 1 year of psychotherapy, plus pharmacologic symptom control (initially, selective serotonin reuptake inhibitors for affective dysregulation and impulsive, disinhibited behavior and neuroleptics for cognitive-perceptual symptoms).

The results of this study would indicate that the prevalence of BPD in a primary care office is 3-6 times that of the community at large (lucky us!). Unfortunately, for our BPD patients, who are prone to suicidal ideation and who have psychiatric comorbidity and functional impairment, we do not recognize them. Disease unrecognized is disease untreated.

(*with apologies to The Eagles.)

References

1. American Psychiatric Association. Quick Reference to the Diagnostic Criteria from DSM-IV. Washington, DC: American Psychiatric Association; 1994:280-281.

2. Davison GC, et al. Abnormal Psychology. New York, NY: John Wiley & Sons, Inc; 1998:338.

3. Hyler SE, et al. Bull Menninger Clin. 1997;61:458-468.

4. Psychiatr Serv. 2001;52:1267.

5. Am J Psychiatry. 2001;158(10 Suppl):1-52.

Dr. Wilke, Assistant Professor of Family Medicine, Medical College of Ohio, Toledo, OH, is Associate Editor of Internal Medicine Alert.