A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience
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[ V O L U M E 1 2 , N U M B E R 7 – 8 , J U L Y – A U G U S T 2 0 1 5 ] Innovations in CLINICAL NEUROSCIENCE 41 T H E I N T E R F A C E 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