MIDAS project
The study population was derived from 3,800 psychiatric outpatients who had been evaluated in the MIDAS project with semi-structured diagnostic interviews.
Of these, 390 patients were diagnosed with BPD. Since the suicidality/self-harm item was not rated in one patient, the analyzed sample consisted of 389 individuals with BPD (28.3% male; mean age, 32.6 years; 86.3% White). A little more than half the participants (54%) met the BPD suicidality/ self-harm criterion.
Only one-fifth (20.5%) of patients with BPD presented with a chief complaint that was related to a feature of BPD and had received BPD as their principal diagnosis.
Patients who met the suicidality/self-injury criterion were almost twice as likely to be diagnosed with BPD as the principal diagnosis, compared with those who did not have that criterion (24.8% vs. 14.5%, respectively; P < .01).
On the other hand, there was no difference in the mean number of BPD criteria that were met, other than suicidality/self-harm, between those who did and did not present with suicidality/self-harm (5.5 ± 1.2 vs. 5.7 ± 0.8, t = 1.44). The investigators note that this finding was “not significant.”
There also was no difference between patients who did and did not meet the criterion in number of psychiatric diagnoses at time of evaluation (3.4 ± 1.9 vs. 3.5 ± 1.8, t = 0.56).
Hidden BPD
Similarly, there was no difference in any specific Axis I or personality disorder – except for generalized anxiety disorder (GAD) and histrionic personality disorder. Both were more frequent in the patients who did not meet the suicidality/self-injury criterion. However, after controlling for age, the group difference in GAD was no longer deemed significant (F = 3.45, P = .064).
By contrast, histrionic personality disorder remained significant with age as the covariate (F = 6.03, P = .015).
“The patients who met the suicidality/self-injury criterion were significantly more likely to have been hospitalized and reported more suicidal ideation at the time of the evaluation,” the researchers write. Both variables remained significant even after including age as a covariate.
There were no between-group differences on severity of depression, anxiety, or anger at initial evaluation nor were there differences in social functioning, adolescent social functioning, likelihood of persistent unemployment or receiving disability payments, childhood trauma, or neglect.
“I suspect that there are a number of individuals whose BPD is not recognized because they don’t have the more overt feature of self-injury or suicidal behavior,” said Dr. Zimmerman, noting that these patients might be considered as having “hidden” BPD.
“Repeated self-injurious and suicidal behavior is not synonymous with BPD, and clinicians should be aware that the absence of these behaviors does not rule out a diagnosis of BPD,” he added.
Stigmatizing diagnosis?
Monica Carsky, PhD, clinical assistant professor of psychology in psychiatry and senior fellow, Personality Disorders Institute, Weill Cornell Medical College, New York, said the study “will be particularly useful in the education of clinicians about the characteristics of individuals with BPD.”
TFP-New York
Dr. Monica Carsky
Dr. Carsky, who is also an adjunct assistant professor in the NYU Postdoctoral Program in Psychoanalysis and Psychotherapy, was not involved with the study. She noted that other factors “can contribute to misdiagnosis of the borderline patients who do not have suicidality/self-harm.”
Clinicians and patients “may see BPD as a stigmatizing diagnosis so that clinicians become reluctant to make, share, and explain this personality disorder diagnosis,” she said.
Dr. Carsky suggested that increasing use of the Alternate Model for Personality Disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), which first rates the severity level of personality by assessing identity and relationship problems and then notes traits of specific personality disorders, “will help clinicians who dread telling patients they are ‘borderline.’ ”
No source of study funding has been reported. The investigators and Dr. Carsky reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.