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Record:1
Title:Investigation of borderline personality disorder among...
Authors:Sansone, Randy A.
Gage, Mark D.
Wiederman, Michael W.
Source:Journal of Mental Health Counseling; Apr98, Vol. 20 Issue 2, p133, 8p, 1 chart
Document Type:Article
Full Text Word Count:2742
ISSN:0193-1830
Accession Number:564231
Persistent link to this record: http://search.epnet.com/login.aspx?direct=true&db=pbh&an=564231
Cut and Paste: <A href="http://search.epnet.com/login.aspx?direct=true&db=pbh&an=564231">Investigation of borderline personality disorder among...</A>
Database: Psychology and Behavioral Sciences Collection

Section: RESEARCH
INVESTIGATION OF BORDERLINE PERSONALITY DISORDER AMONG NONPSYCHOTIC, INVOLUNTARILY HOSPITALIZED CLIENTS


Many nonpsychotic individuals are involuntarily hospitalized in psychiatric facilities due to dangerousness to self and/or others Accordingly, the current investigation was designed to explore the prevalence of borderline personality disorder (BPD) among this client group. Thirty-two clients who were involuntarily hospitalized in a psychiatric facility were assessed for BPD using three measures (ie., an interview and two self-report questionnaires). Among participants, 84.4% met criteria for BPD based on clinical interview, 56.3% based on the Personality Diagnostic Questionnaire-Revised, and 75% teased on the Self-Harm Inventory. The majority (53.1%) met criteria for BPD on all three measures, 18.8% on two measures, and 18.8% on only one measure. Only three participants (9.4%) did not meet criteria for BPD on any measure These findings suggest that the majority of nonpsychotic involuntarily hospitalized clients exhibit borderline personality features or disorder.

Previous studies indicate that clients who are involuntarily hospitalized or detained in a psychiatric facility are likely to have a psychotic disorder. Wood and Swanson (1985) reported that 89% of their involuntary sample met the diagnostic criteria for a psychotic disorder. Mahler and Co (1984) found that schizophrenia accounted for nearly 70% of the diagnoses among involuntarily hospitalized clients whose detentions were subsequently supported by court decision. Sanguineti, Samuel, Schwartz, and Robeson (1996) reported that the diagnoses of schizophrenia and psychosis not otherwise specified accounted for nearly 62% of involuntary admissions in their study sample. In a final study, among psychiatric clients who were both involuntarily hospitalized and also had histories of criminal arrest, 58% met criteria for schizophrenia, bipolar disorder, or acute psychosis (Bloom, Shore, & Arvidson, 1981).

Little is known, however, about the diagnoses of nonpsychotic clients who are involuntarily admitted to psychiatric facilities, particularly with regard to the prevalence of personality disorder. Sanguineti et al. (1996) indicated that about 3% of their involuntary sample had a personality disorder, but these investigators did not identify specific clusters or personality disorder diagnoses Bloom et al. (1981) reported that, among involuntarily hospitalized clients with an arrest history, 26% had personality disorder, again without notation of specific diagnoses. Finally, Coid (1992) reported findings on a diverse sample that was composed of several divergent subsamples, two of which consisted of criminal "psychopaths" involuntarily hospitalized in a psychiatric facility. He found that many clients had more than one personality disorder diagnosis, as well as Axis-I diagnoses. Borderline and antisocial personalities were the most prevalent Axis II disorders, often in combination, followed by narcissistic personality disorder (all Cluster B disorders).

In keeping with our experience, several investigators have indicated that involuntary hospitalizations are commonly precipitated by dangerousness towards others or oneself (Gunderson & Singer, 1975; Richert & Moyes, 1983; Rubin & Mills, 1983). Specifically, Rubin and Mills (1983) reported that many civilly committed clients had either threatened or began to take some action directed against others (48%) or themselves (34%). Given that many involuntary hospitalizations are undertaken because of dangerousness to self or others, the possibility of borderline personality disorder is suggested because of the associated symptoms of rage reactions and self-destructive behavior (Gunderson & Singer, 1975; Linehan, 1987; Mack, 1975; Walsh & Rosen, 1988). The current investigation was designed to explore the prevalence of BPD among involuntarily hospitalized clients in a psychiatric facility using three measures for the disorder (clinical interview and two self-report measures).

METHOD

Participants

Participants were 16 male and 16 female clients, all nonpsychotic, who were involuntarily hospitalized at an urban psychiatric hospital that functions as the hospital facility for the local community mental health system. Four participants (2 men, 2 women) had pending legal charges. Participants ranged in age from 18 to 63 years with a mean age of 36.16 years (SD = 13.33). Eight (25%) had never been married, 10 (31.3%) were married, 12 (37.5%) were divorced, and the remaining 2 (6.3%) were widowed. With regard to education, 7 (21.9%) had not completed high school, 9 (28.1%) had attained a high school diploma, 9 (28.1%) had taken some college courses, and the remaining 7 (21.9%) had earned an associate's or bachelor's degree. There were no gender differences with regard to these variables. Race or ethnicity was not determined for this sample. These 32 individuals represented a response rate of 84.2%.

Procedure

All participants were involuntarily hospitalized. Each was consecutively recruited onsite on Thursday afternoons during a 3-month study period by a fourth-year resident in psychiatry. After an introduction to the project, each participant signed a voluntary consent form.

Each participant completed a clinical interview onsite, conducted by the resident, as well as a research booklet. The clinical interview was based on the criteria for BPD as presented in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (American Psychiatric Association, 1994). Each criterion was rated as present, probably present, or not present. In keeping with DSM-IV (1994) requirements, five of nine criteria (each rated as present) were necessary for the diagnosis of BPD.

The 3-page research booklet contained three sections. The first explored demographic information, the presence of pending legal charges, past psychiatric hospitalizations, and previous convictions for crimes. The second section contained the borderline personality scale of the Personality Diagnostic Questionnaire-Revised (PDQ-R) (Hyler & Rieder, 1987), an 18-item, self-report questionnaire. This measure has been reported to be a useful screening measure for borderline personality in both clinical (Dubro, Wetzler, & Kahn, 1988; Hyler et al., 1990) and nonclinical samples (Johnson & Bornstein, 1992).

The third section of the research booklet contained the Self-Harm Inventory (SHI), a 22-item self-report measure that explores respondents' history of self-destructive behavior (Sansone, Wiederman, & Sansone, in press). Each item is preceded by the statement, "Have you ever intentionally, or on purpose, ..." and individual items include overdosed, cut yourself on purpose, burned yourself on purpose, hit yourself, banged your head, scratched yourself on purpose, and attempted suicide. The endorsement of 5 or more items appears to predict for BPD with an accuracy rate of 83.7% (Sansone et al., in press), according to diagnostic assessment using the Diagnostic Interview for Borderlines (Kolb & Gunderson, 1980), a well-recognized assessment instrument for BPD. Following participation, each individual was paid $2.00.

RESULTS

There were multiple indications of long-standing maladjustment among many of the participants. For example, of the total sample, 21 (65.6%) reported more than one psychiatric hospitalization, with 9 (28.1%) indicating four or more psychiatric hospitalizations. Also, 11 (34.4%) of the respondents had been convicted of a crime, with most (54.5%) of those having been convicted of multiple crimes.

With regard to the prevalence of BPD among the sample, 27 (84.4%) met criteria according to DSM-IV (1994). Using the clinical cut-off score of 5 on the borderline personality scale of the PDQ-R, 18 (56.3%) met or exceeded the cut-off score.

With regard to self-harm behaviors, the sample as a whole displayed multiple types. The number of participants who endorsed each of the 22 self-harm behaviors on the SHI are presented. (See Table.) Incidence of self-harm behavior ranged from a low of 6.3% for having abused laxatives to a high of 71.9% for having attempted suicide. There were statistically significant gender differences on four of the SHI items. More women (87.5%) than men (56.3%) indicated that they had attempted suicide, X2 (1,N = 32) = 3.86, p < .05. Similarly, more women (81.3%) than men (31.3%) reported having overdosed, X2 (1,N = 32) = 8.13, p < .005. Women (56.3%) were also more likely than men (18.8%) to have distanced themselves from God as punishment, X2 (1,N = 32) = 4.80, p < .03. Only with regard to driving recklessly on purpose did more men (50.0%) than women (12.5%) indicate having engaged in the behavior, X2 (1,N = 32) = 5.24,p < .03. Using the suggested cut-off of 5 on the SHI, 24 (75%) participants met criteria for borderline personality.

In comparing the probability of a borderline diagnosis based on the three different measures, 17 (53.1%) met criteria on all three measures, 6 (18.8%) on two measures, and 6 (18.8%) on only one measure. Three clients (9.4%) did not meet criteria for BPD on any measure.

DISCUSSION

The findings of the current study indicate that the majority of nonpsychotic, involuntarily hospitalized clients in this sample had BPD. The symptomatology of this personality disorder would be consistent with several of the known reasons for involuntary admission, specifically a danger to others or oneself. The high prevalence of BPD is also consistent with the clinical profile of this sample (e.g., committing of crimes, multiple psychiatric hospitalizations).

Note that the three measures used in this study to assess for BPD entail different formats (interview versus self-report), conceptualizations (e.g., DSM-IV definition versus behavior history of the SHI), and types of items. Despite these differences, 53.1% of the sample met diagnostic criteria on all three measures. This strongly suggests that, regardless of the particular focus or conceptualization, participants' psychopathology bridged the differences among these various measures for BPD.

In examining participants' self-destructive behaviors, the majority reported attempting suicide, overdoses, abuse of alcohol, engagement in emotionally abusive relationships, and torturing of oneself with self-defeating thoughts This descriptive panorama of self-destructive behaviors is consistent with the clinical features found in BPD and suggests a high level of internal chaos among participants in this study.

From a clinical perspective, these data indicate that, among those individuals who are nonpsychotic and involuntarily hospitalized, BPD is a frequent diagnosis. Therefore, it would seem appropriate for mental health professionals to carefully screen all nonpsychotic, involuntary hospitalized individuals for this diagnosis. Because this diagnosis is characterized by self-regulation difficulties and self-destructive behaviors, clinicians need to anticipate among these individuals the possibilities of substance abuse (particularly substance dependence, which may be overlooked during an emergent hospitalization until the appearance of a withdrawal syndrome), eating disorders (particularly bulimia among female clients), and self-mutilation or suicide attempts precipitated by the stress of hospitalization. In addition, some individuals with BPD are prone to dissociative defenses under stress, which may become apparent during hospitalization.

While involuntary hospitalization, itself, is intended to provide a necessary environment for the containment of unacceptable or threatening behaviors, one potential risk among clients with BPD is the possibility of in-hospital regression (Sansone & Madakasira, 1990). Therefore, it is important to continually weigh the risks and benefits of the hospitalization experience and, when feasible and safe, advance these individuals to less restrictive environments as the clinical situation allows.

During hospitalization, effective treatment planning for aftercare is necessary and can be challenging given the potential multitude of difficulties these individuals may be experiencing. With discharge planning, mental health professionals must decide the role of psychotherapy, cognitive-behavioral interventions, life-management skills training, psychotropic medication, future role of hospital intervention, and crisis planning (Sansone & Madakasira, 1990). Comorbid psychiatric disorders, such as substance abuse or eating disorders, may need to be addressed through adjunctive treatment resources (e.g., 12-step programs, eating-disorder treatment programs). Finally, the mental health professional may need to work with the client's legal council to provide education about this particular personality disorder and it's role in any legal complications.

The limitations of this investigation are as follows. First, the overall sample size is relatively small. Second, there may be differences in involuntary hospitalization patterns among psychiatrists and facilities, which might compromise the ability to generalize from these data. Third, the presence of Axis I or other Axis II disorders was not assessed; therefore, we are unable to speculate about the clinical features that characterize these clients from the broader heterogeneous group of individuals with BPD. The strengths of this study include the novel focus and the use of three different measures for BPD (including a diagnostic interview).

With regard to working with individuals who have BPD, our findings suggest that the clinician should be sensitive to the possible risk of involuntary hospitalization among the other risks associated with borderline personality (e.g., suicide attempts, self-mutilation, psychotic transferences). These findings also indicate another potential element in the healthcare cost equation for such clients. Whether these involuntarily hospitalized individuals differ from the general population of individuals with BPD warrants further investigation.

Individuals with BPD may constitute the majority of nonpsychotic involuntarily hospitalized clients. The associated symptoms of rage reactions and self-destructive behaviors may account for involuntary admissions because of dangerousness to others or to oneself. The characteristics that may differentiate involuntarily hospitalized clients with BPD from the general heterogeneous population of individuals with BPD warrants further investigation.

Research participants who endorsed each of 22 intentional self-harm behaviors (N = 32)

Self-Harm Behavior                              Endorsed   n %

Overdosed                                           18     56.3
Cut self                                            13     40.6
Burned self                                          4     12.5
Hit self                                             6     18.8
Banged head                                         12     37.5
Scratched self                                       4     12.5
Attempted suicide                                   23     71.9
Prevented wounds from healing                        6     18.8
Made medical situations worse                        7     21.9
Abused prescription medication                      12     37.5
Exercised an injury on purpose                       7     21.9
Starved self on purpose                              9     28.1
Abused laxatives to hurt self                        2      6.3
Abused alcohol                                      22     68.8
Driven recklessly on purpose                        10     31.3
Been sexually promiscuous                           12     37.5
Lost a job on purpose                                9     28.1
Set self up to be rejected in a relationship         8     25.0
Distanced self from God as punishment               12     37.5
Engaged in emotionally abusive relationships        20     62.5
Engaged in sexually abusive relationships           10     31.3
Tortured self with self-defeating thoughts          22     68.8

REFERENCES

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author

Bloom, J. D., Shore, J. H., & Arvidson, B. (1981). Local variations in arrests of psychiatric patients. Bulletin of the American Academy of Psychiatry and the Law, 9, 203-209.

Coid, J. W. (1992). DSM-III diagnosis in criminal psychopaths: A way forward. Criminal Behavior and Mental Health, 2, 78-94.

Dubro, A. E, Wetzler, S., & Kahn, M. W. (1988). A comparison of three self-report questionnaires for the diagnosis of DSM-III personality disorders. Journal of Personality Disorders, 2, 256-266.

Gunderson, J. G., & Singer, M. T. (1975). Defining borderline patients: An overview. American Journal of Psychiatry, 132, 1-10.

Hyler, S. E., Lyons, M., Rieder, R. O.,Young, L.,Williams,J. B. W. & Spitzer, R. L. (1990).The factor structure of self-report DSM-III Axis II symptoms and their relationship to clinicians' ratings. American Journal of Psychiatry, 147, 751-757.

Hyler, S. E., & Rieder, R. O. (1987). Personality Diagnostic Questionnaire-Revised New York: New York State Psychiatric Institute.

Johnson,J. G., & Bornstein, R. E (1992). Utility of the Personality Diagnostic Questionnaire-Revised in a nonclinical population. Journal of Personality Disorders, 6, 450-457.

Kolb, J. E., & Gunderson, J. G. (1980). Diagnosing borderline patients with a semistructured interview. Archives of General Psychiatry, 37, 37-41.

Linehan, M. M. (1987). Dialectical behavior therapy for borderline personality disorder: Theory and method. Bulletin of the Menninger Clinic, 51, 261-276.

Mack, J. (1975). Borderline states: An historical perspective. New York: Grune & Stratton.

Mahler, H., & Co, B. T. (1984). Who are the "committed"? Journal of Nervous and Mental Disease, 172, 189-196.

Richert, R. A., & Moyes, A. H. (1983). Reasons for involuntary commitment in Manitoba and Ontario. Canadian Journal of Psychiatry, 28, 358-361.

Rubin, L. C., & Mills, M. J. (1983). Behavioral precipitants to civil commitment. American Journal of Psychiatry, try, 140, 603-606.

Sanguineti, V. R., Samuel, S. E., Schwartz, S. L., & Robeson, M. R. (1996). Retrospective study of 2,200 involuntary psychiatric admissions and readmissions. American Journal of Psychiatry 153, 392-396.

Sansone, R. A., & Madakasira, S. (1990). Borderline personality disorder. Guidelines for evaluation and brief inpatient management. The Psychiatric Hospital, 21, 65-69.

Sansone, R. A., Wiederrnan, M. W., & Sansone, L. A. (In press). The self-harm inventory: A measure for identifying self-harm behaviors and borderline personality disorder. Journal of Clinical Psychology.

Walsh, B. W., & Rosen, P.M. (1988). Self-mutilation. New York: Guilford Press.

Wood, W. D., & Swanson, D. A. (1985). Use of outpatient treatment during civil commitment: Law and practice in Nebraska. Journal of Clinical Psychology, 41, 723-728.

~~~~~~~~

By Randy A. Sansone, Mark D. Gage and Michael W. Wiederman

Randy A. Sansone, M.D., is an associate professor in the Department of Psychiatry at Wright State University School of Medicine and director of Psychiatric Education for Primary Care at Kettering Medical Center. Mark D. Gage, D.O., is the medical director of the Center for Gerosychiatry at Henryetta Medical Center in Henryetta, OK Michael W. Wiederman, Ph.D., is an assistant professor in the Department of Psychological Science at Ball State University in Muncie, IN. This research endeavor was undertaken at Parkside Hospital, a teaching hospital of the Department of Psychiatry, in Tulsa, OK Please address all correspondence to Dr. Sansone, Sycamore Primary Care Group, 2150 Leiter Road, Miamisburg, OH 45342.


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Source: Journal of Mental Health Counseling, Apr98, Vol. 20 Issue 2, p133, 8p
Item: 564231
 
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