This study examines the degree to which an eating disorder (ED) is associated with the recurrence and severity of suicide attempts, non-suicidal self-injury, rates of co-occurring Axis I and II disorders, and psychosocial functioning among Borderline Personality Disorder (BPD) outpatients. A group of 135 treatment-seeking women with BPD were assessed using structured clinical interviews. BPD was assessed using the International Personality Disorders Examination, confirmed by the Structured Clinical Interview for DSM-IV (SCID)-II, and Axis I disorders were assessed with the SCID I. A total of 17.8% of the sample met criteria for a current ED, with 6.7% meeting criteria for Anorexia Nervosa (AN), 5.9% for Bulimia Nervosa (BN), and 5.2% for Binge-Eating Disorder (BED). In this BPD sample, in the last year, current BN was associated with a significantly greater risk of recurrent suicide attempts while current AN was associated with increased risk of recurrent non-suicidal self-injury. BPD with current AN or BED was associated with a greater number of non-ED current Axis I disorders. Further replication of these results is needed. Women with BPD must be assessed for AN and BN as these diagnoses may confer greater risk for suicidal and self-injurious behavior and may have to be prioritized in treatment.
Borderline Personality Disorder (BPD) is a serious chronic mental illness marked by recurrent suicide attempt or non-suicidal self-injury (deliberate behavior causing physical damage but without intent to die) with up to 10% committing suicide (Lieb et al., 2004). BPD is also typified by multiple Axis I and II disorders and poor psychosocial functioning (Lieb et al., 2004).
Multiple studies examine rates of BPD in eating disorder (ED) samples (see Cassin and von Ranson, 2005 and Levitt et al., 2004), although few examine the rates of EDs in BPD samples. About half of treatment-seeking BPD women report a lifetime ED diagnosis (‘lifetime’ referring in this and following studies to past and current unless otherwise indicated) (Zimmerman and Mattia, 1999). Of 298 female inpatients with BPD, 25% reported lifetime Anorexia Nervosa (AN) (Zanarini et al., 1998) and 27% reported lifetime Bulimia Nervosa (BN) (Marino and Zanarini, 2001). Up to 33% of a treatment-seeking BPD sample reported lifetime EDs not otherwise specified, with 37% having Binge-Eating Disorder (BED) (Marino and Zanarini, 2001 and Grilo et al., 2003).
Little has been published comparing BPD groups with and without EDs on variables such as suicidal behavior and non-suicidal self-injury, number of Axis I and II disorders, and psychosocial functioning. These studies are needed to establish what behaviors to prioritize in treatment. A study by Dulit et al. (1994) is one of the few that has examined the association of EDs with non-suicidal self-injury in BPD. Using a sample of 124 inpatients with BPD, this study found that BPD individuals with BN were 4 times as likely to engage in frequent self-injury (≥ 5 lifetime acts of non-suicidal self-injury) compared with no self-injury. Frequent self-injurers were more likely to have current AN, but this finding failed to reach significance. Additionally, Zanarini et al. (2004) found that absence of an ED improves the odds of BPD remission.
The relationships between EDs and suicidal behavior and non-suicidal self-injury have been examined primarily in ED samples. Some studies suggest that suicide attempts and non-suicidal self-injury are found in more than half of BN samples (Franko and Keel, 2006 and Svirko and Hawton, 2007). These rates appear higher in BN than in AN, although there are suggestions of similar rates of this behavior in the AN binge-eating/purging subtype as in BN (Favaro and Santonastaso, 2000 and Nagata et al., 2000). In BED, suicidal behavior appears higher than that for obese non-BED controls (Grucza et al., 2007). Finally, the medical lethality of suicide attempts does not appear to differ between ED groups (Bulik et al., 1999).
The co-occurrence of Axis I and II disorders has been examined in ED samples but has not been examined in BPD samples with EDs. AN and BN groups with suicidal behavior or non-suicidal self-injury report greater numbers of Axis I and II disorders such as drug or alcohol abuse, anxiety disorders and depression (Fedorowicz et al., 2007 and Franko et al., 2004). Other studies with ED samples have found that AN and BN are associated with major depression (Berkman et al., 2007). Restricting subtype AN is found to be associated with obsessive-compulsive disorder (O'Brien and Vincent, 2003). Finally, the AN binge-eating/purging subtype and BN are associated with alcohol use disorders (Bulik et al., 2004).
It is unclear as to whether BPD with EDs is associated with poorer psychosocial functioning than BPD alone. ‘Multi-impulsive BN’ (BN with other impulse-control Axis I disorders) compared with BN alone is associated with lower psychosocial functioning (Fichter et al., 1994). Lower psychosocial functioning is also found in a group with personality disorders (PDs) and EDs compared with BN alone is (Skodol et al., 1993). However, Dulit et al. (1994) found no difference in psychosocial functioning between frequent, infrequent and non-self-injurers with BPD, where frequent self-injury was more associated with EDs.
In this BPD sample, it is hypothesized that there will be an increased likelihood of recurrent suicide attempts and non-suicidal self-injury in individuals with EDs, particularly BN. It is unclear, however, whether the severity of suicide attempts/non-suicidal self-injury, number of co-occurring Axis I and Axis II disorders, and psychosocial functioning will differ between individuals with and without EDs in this BPD sample.
