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) 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.

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