Borderline Personality Disorder in the Medical Setting: Suggestive Behaviors, Syndromes, and Diagnoses

| August 13, 2015 | 0 Comments

Sansone_J_A_2015_Artby Randy A. Sansone, MD, and Lori A. Sansone, MD
R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, OH, and Director of Psychiatry Education at Kettering Medical Center in Kettering, OH. L. Sansone is a civilian family medicine physician at the Primary Care Clinic at Wright-Patterson Air Force Base in Dayton, OH. The views and opinions expressed in this article are those of the authors and do not reflect the official policy or position of the United States Air Force, Department of Defense, or United States Government.

Innov Clin Neurosci. 2015;12(7–8):39–44

This ongoing column is dedicated to the challenging clinical interface between psychiatry and
primary care—two fields that are inexorably linked.

Funding: There was no funding provided for the preparation of this article.

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

Abstract: Borderline personality disorder is a personality dysfunction that is characterized by disinhibition and impulsivity, which oftentimes manifest as self-regulation difficulties. Patients with this disorder have always been present in medical settings, but have been described as “difficult patients” rather than patients with borderline personality disorder. According to empirical findings, a number of behaviors and medical syndromes/diagnoses are suggestive of borderline personality disorder. Suggestive behaviors in the medical setting may include aggressive or disruptive behaviors, the intentional sabotage of medical care, and excessive healthcare utilization. Suggestive medical syndromes and diagnoses in the medical setting may include alcohol and substance misuse (including the abuse of prescription medications), multiple somatic complaints, chronic pain, obesity, sexual impulsivity, and hair pulling. While not all-inclusive or diagnostic, these behaviors and syndromes/diagnoses may invite further clinical evaluation of the patient for borderline personality disorder.

Key words: Borderline personality, borderline personality disorder, healthcare, healthcare utilization, somatic, somatic preoccupation

Introduction

Borderline personality disorder (BPD) is a challenging personality dysfunction that is characterized by chronic disinhibition and impulsivity, which oftentimes culminates in self-regulation difficulties. In addition, these patients frequently display chronic self-destructive behavior. While well known in psychiatric settings, recognition of this disorder and its possible manifestations in the medical setting is continuing to unfold. As in psychiatric settings, BPD may be heralded by numerous suspicious behaviors and syndromes/diagnoses in the medical setting, although none of these are, by themselves, diagnostic. In this edition of The Interface, we discuss the accumulating empirical evidence related to the clinical manifestations of BPD in the medical setting, much of which includes our own investigations in this area.

The Prevalence of BPD in Medical Settings

The prevalence of personality disorders in medical settings is under-researched, but individuals with personality dysfunction appear to be commonplace and have been customarily identified by clinicians in these settings as “difficult patients.” To our knowledge, no extensive large-scale study has simultaneously examined prevalence rates of various personality disorders within a single large sample of primary care outpatients. However, Gross et al[1] explored the prevalence of BPD among internal medicine outpatients in a private-practice setting and determined a rate of 6.4 percent. Likewise, during several empirical endeavors, we have examined rates of BPD symptomatology among internal medicine outpatients in a resident-provider setting and encountered rates between 18 and 25 percent.[2] As for specialty medical settings, in a cardiac stress testing setting, we determined a prevalence rate for BPD of 8.8 percent among patients undergoing evaluation.[3]

Patient Behavioral Patterns Suggestive of BPD Symptomatology

Patients in medical settings may display various behaviors that are suggestive, but not diagnostic, of BPD. These behaviors are typically characterized by disinhibition and impulsivity, which is predictably longitudinal and pervasive in nature (i.e., repetitive longstanding patterns). Moreover, these behaviors may reflect self-regulation struggles. The following empirically confirmed behaviors are relatively commonplace among patients with BPD in the primary care setting.

Aggressive or disruptive behaviors in the medical setting. A number of aggressive or disruptive behaviors are clinically associated with BPD (i.e., refusing treatment, angry outbursts that are grossly out-of-proportion to the situation, demandingness, or intimidation). To further clarify the range of poor patient conduct in medical settings, we explored, in a survey of internal medicine outpatients, the prevalence of 17 disruptive office behaviors and their relationship to BPD symptomatology.[4] In this study, the number of different disruptive office behaviors reported by participants was correlated with BPD as well as the following specific office behaviors—yelling, screaming, making verbal threats, refusing to talk to medical personnel, and talking disrespectfully about medical personnel to both family and friends.[4] Fortunately, none of the preceding behaviors are physically threatening to the clinician.

The intentional sabotage of medical care. The intentional sabotage of medical care melds well with BPD as such behaviors may function as self-injury equivalents (i.e., less recognizable variants of self-harm behavior).[5] One clinical example is intentionally making medical situations worse. In support of this impression, in a compiled sample of 332 internal medicine outpatients,[6] we found that 16.7 percent of participants acknowledged intentionally making medical situations worse; in addition, this phenomenon demonstrated a statistically significant relationship with BPD.

We have also examined a behavior affiliated with making medical situations worse—exercising an injury on purpose.[7] To examine this phenomenon, we compiled four databases (1,511 internal medicine outpatients) and found that 2.9 percent of participants reported intentionally exercising an injury on purpose, and this behavior was statistically associated with BPD.

Another possible behavioral variation of making medical situations worse is the phenomenon of preventing wounds from healing. To explore this possibility, we examined the prevalence of this behavior in an internal medicine outpatient sample, and found that 4.2 percent of participants engaged in preventing wounds from healing.[8] We subsequently found statistical associations between preventing wounds from healing and BPD in three study samples (i.e., a sample of internal medicine outpatients, an obstetrics/gynecology sample, and a compiled sample of mixed outpatients).[5,9,10]

Excessive healthcare utilization patterns. Excessive healthcare utilization and resulting high healthcare costs are ardent issues in today’s fiscal climate. Not surprisingly, BPD appears to be one of the contributory variables. In support of this impression, in a study of internal medicine outpatients, we found that over the preceding five years, participants with BPD symptomatology were significantly more likely to see a greater number of primary care physicians compared to participants without this personality dysfunction.[11] In addition, we found that compared to their nonBPD peers, patients with BPD features consistently evidenced a greater number of office visits and documented prescriptions,[12,13] more contacts with the treatment facility (e.g., telephone calls),[13] and more frequent referrals to specialists[14]—i.e., an overall greater utilization of healthcare resources.

Syndromes and diagnoses with possible associations with BPD

Beyond the preceding sampling of patient behaviors that are suggestive of BPD in primary care settings, several syndromes and diagnoses may be suggestive of or associated with BPD, as well. Importantly, not every patient who harbors these types of symptom profiles will have BPD and likewise, not every individual with BPD displays these types of symptom profiles. None-the-less, these diagnostic patterns may be the impetus for reviewing a patient’s personality functioning in a more formal manner.

Alcohol/substance use disorders. According to the extant literature, there is a frequent linkage between substance use disorders and BPD—not a surprising finding given that self-regulation issues are entailed in both disorders. A review of this literature revealed four studies denoting lifetime prevalence rates for substance misuse in patients with BPD, which averaged 64 percent.[15] In other words, two-thirds of patients with BPD have experienced substantial substance-use problems at some point during their lifetimes. In the medical setting, preferred substances include benzodiazepines, opiates, and stimulants.[16]

Prescription misuse is a specific variant of substance use disorder. Among internal medicine outpatients, we found a self-reported rate of prescription-medication misuse of 9.2 percent,[17] with no differences between men and women.[18] (Given that these data are self-report, the genuine rate is likely to be higher, as some participants may have been too embarrassed to acknowledge misuse, feared legal action, or denied misuse.) In two different study samples, one comprising both psychiatric inpatients and internal medicine outpatients and a second comprising internal medicine outpatients only, we confirmed a relationship between the self-reported misuse of prescription medications and BPD symptomatology.[17,19] While the underlying reasons for prescription misuse remain unclear, contributory explanations may include sensation-seeking, blocking traumatic memories, and/or experimenting with self-harm behavior.

Multiple somatic complaints. A number of authors have identified relationships between multiple somatic symptoms and BPD. This relationship may be partially explained by the patient’s inculcation of a victim role in adulthood coupled with the need to elicit caring responses from others. Perhaps most dramatic, this phenomenon may manifest as somatization disorder—a previous DSM concept. In this regard, Prasad et al[20] identified a subset of patients with BPD and somatization disorder; Hudziak et al[21] confirmed the presence of somatization disorder in 36 percent of patients with BPD; and Spitzer and Barnow[22] described distinct relationships between somatoform disorders and BPD.

In addition to somatization disorder, a number of authors have described clinical relationships between somatic preoccupation, a broader, less dramatic, and more clinically relevant phenomenon, and BPD.[23–25] Moreover, empirical research has confirmed such relationships. For example, using psychological tests, Lloyd et al[26] found a relationship between BPD and a proneness to reporting somatic complaints. In an initial study, we found a moderate statistical correlation between somatic preoccupation and BPD symptomatology among a sample of internal medicine outpatients.[2] In a second sample of internal medicine outpatients, we found for this relationship statistically significant correlations in the moderate-to-high range.[27] In a study using path analysis as the analytic approach, we confirmed among family-medicine outpatients a relationship between somatic preoccupation and BPD symptomatology.[28] In a final study of this phenomenon, we used a 35-item medical review of systems for the assessment of somatic preoccupation in a sample of internal medicine outpatients and found that the total number of symptoms endorsed on the medical review of systems was positively correlated with BPD symptomatology.[29] In this final study, no individual symptom or symptom pattern was particularly evident among participants with BPD features—somatic symptoms were panoramic and diverse.

Chronic pain syndromes. Chronic pain can readily be conceptualized as a self-regulation difficulty (i.e., the inability to regulate pain), and therefore feasibly related to BPD. To explore this relationship, we reviewed the prevalence of BPD among eight empirical samples of individuals with various types of chronic pain syndromes.[30] Among these published studies, the averaged prevalence rate for BPD was 30 percent. In addition to the denoted prevalence rate, these data indicate that individuals with BPD tend to report higher levels of pain than participants without BPD; older individuals with BPD are more likely to report higher pain levels than younger patients with BPD; and the first-degree relatives of participants with BPD have higher-than-expected rates of somatoform pain disorder. However, we found that the prevalence of medical disability among chronic-pain participants with versus without BPD did not substantially differ. In a final study of this relationship among internal medicine outpatients, using visual analog scales, we examined pain levels at the time of the assessment, over the past month, and over the past year as well as pain catastrophizing; each pain assessment as well as the tendency to catastrophize pain exhibited statistically significant correlations with two measures of BPD symptomatology at the p<0.001 level.[31]

Obesity. Given that obesity is clearly a multidetermined disorder, one relevant contributory variable may be BPD pathology (impulsivity or self-regulation difficulties culminating in overeating behavior). In our literature review of nine studies, all with various measures and populations (five samples from bariatric surgery sites), the averaged prevalence rate of BPD on all measures was 27 percent[32]—a percentage that is at least four and a half times the rate of BPD encountered in the general population (2–6%).[33,34] Because more than half of these samples were recruited from bariatric surgery sites and assessments were undertaken prior to surgery, it is likely that a meaningful proportion of participants under-reported symptoms (i.e., failed to endorse classic BPD symptoms such as self-mutilation, suicide attempts, alcohol/substance abuse) in order to secure the surgery. Thus, the reported averaged prevalence rate is likely to be low.

Sexual impulsivity. Impulsivity and self-destructive behavior can readily extend to sexual behavior. In a review of the literature, in comparison with controls, we found that various authors have reported among BPD patients the following: 1) greater sexual preoccupation as well as sexual dissatisfaction; 2) promiscuity in the presence of comorbid substance abuse; 3) higher number of casual sexual relationships; 4) more frequent high-risk sexual behaviors; 5) higher prevalence rate of sexually transmitted diseases; 6) higher number of homosexual experiences; 7) earlier sexual experiences; 8) greater likelihood of date rape; 9) overall greater number of sexual partners; and 10) greater likelihood of experiences with sexual coercion.[35]

The preceding review included our own three studies in the area of sexual behavior and BPD.[35] In the first study, which was among women in an internal medicine outpatient setting, we found that those participants with BPD symptomatology were more likely to report earlier sexual experiences as well as higher rates of date rape.[36] In a second study of our own compiled datasets, we found that participants with BPD symptomatology were twice as likely to endorse casual sexual relationships (a lack of familiarity with partners) as well as promiscuity (multiple sexual partners) than participants without these symptoms.[37] Finally, in a third study among internal medicine outpatients, we found that participants with BPD features reported twice the number of different sexual partners than participants without this personality dysfunction.[38]

Overall, findings generally indicate that individuals with BPD tend to have more sexual experiences, a greater number of sexual partners, and a broader range of sexual experiences. This conclusion may clinically manifest in higher rates of sexually transmitted diseases.

Hair pulling. Hair pulling may be conceptualized in some individuals as both impulsive and self-destructive; therefore, a relationship with BPD might be implicated. We have examined hair pulling, or trichotillomania, in two separate studies. In the first study, among internal medicine outpatients, we found a prevalence rate of 2.9 percent as well as statistical associations with BPD according to two self-report measures for this disorder.[39] In a second study among women in an obstetrics/gynecology clinic, we found a prevalence rate of 7.2 percent as well as statistical associations with BPD.[40]

Conclusion

Undeniably, individuals with BPD in the medical setting are a genuine challenge for clinicians. Described in the past as “difficult patients,” these individuals are typically characterized by impulsivity and oftentimes self-regulation difficulties. Suggestive behaviors in the medical setting include aggressive or disruptive behaviors, intentional sabotage of medical care, and excessive healthcare utilization. Syndromes and diagnoses suggestive of BPD include alcohol and substance use disorders as well as the abuse of prescription medications, multiple somatic complaints, chronic pain, obesity, sexual impulsivity, and hair pulling. These examples are not all-inclusive, but rather reflect the current state of research. Future research might further examine the prevalence of personality disorders in various medical settings (e.g. rheumatology), the prevalence of personality disorders with regard to specific syndromes/diagnoses (e.g., fibromyalgia), and intervention techniques in this under-researched subset of patients. The intersection of personality pathology and the medical setting poses intriguing treatment issues. Hopefully, further research will clarify and improve the identification and management of these challenging individuals in the primary care setting.

References

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3. Sansone RA, Dittoe N, Hahn HS, Wiederman MW. The prevalence of borderline personality disorder in a consecutive sample of cardiac stress test patients. Prim Care Companion CNS Disord. 2011;13(3):pii: PCC.10?01087.
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Category: Impulse Control Disorders, Medical Issues, Past Articles, Personality Disorders, Primary Care, Psychiatry, The Interface

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