A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience
Issue link: https://innovationscns.epubxp.com/i/555782
Innovations in CLINICAL NEUROSCIENCE [ 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 ] 42 T H E I N T E R F A C E 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. 3 7 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 1. Gross R, Olfson M, Gameroff M, et al. Borderline personality disorder in primary care. Arch Int Med. 2002;162:53–60. 2. Sansone RA, Wiederman MW, Sansone LA. Medically self-harming