سوء استفاده های دوران کودکی، استفاده از مراقبت های بهداشتی روانی، رفتار خودآسیبی و تشخیص های متعدد روان پزشکی در میان بیماران با و بدون تشخیص مرزی

Abstract Although borderline personality disorder (BPD) has defined diagnostic criteria, a number of other clinical features are associated with this diagnosis. These features may include childhood histories of abuse (eg, sexual, physical, and emotional abuse; the witnessing of violence), high mental healthcare utilization, self-harm behavior, and polysymptomatic presentations that result in multiple Axis I diagnoses. Although each of these variables has been described in the empirical literature, only 1 other study has explored all 4 of these variables in a single study population—the Collaborative Longitudinal Personality Disorders Study. Using clinical diagnoses and self-report surveys, we explored these variables among psychiatric inpatients in a community hospital. We found that, compared with patients with no BPD, those with BPD reported significantly more types of childhood trauma, higher utilization of particular mental health services (ie, number of times and days of hospitalization for mental health or substance abuse, number of psychiatrists and therapists ever seen, number of courses of psychotherapy treatment), and a higher number of self-harm behaviors. Although not significant, there were positive trends for the remaining variables. The authors discuss the implications of these findings as they relate to patients with BPD.

1. Introduction According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) [1], a variety of clinical criteria are associated with borderline personality disorder (BPD). Although these criteria have been empirically confirmed, the research literature indicates that several additional clinical features may be associated with BPD. 1.1. Childhood abuse Many patients with BPD report childhood histories of trauma [2]. The literature on the relationship between childhood trauma variables and BPD in adulthood is extensive and beyond the scope of this paper. However, Sabo [3] and Goodman and Yehuda [4] provide excellent summaries of this material and the results from the Collaborative Longitudinal Personality Disorders Study indicate that, compared with other personality disorders, those with BPD reported higher rates of childhood traumatic exposure [5]. Childhood abuse may include sexual, physical, and emotional abuse. In some studies, the witnessing of violence is an additional trauma variable, although its influence in the development of BPD may be dependent upon the victim's age. 1.2. High mental healthcare utilization Several researchers have confirmed the finding of high mental healthcare utilization among those with BPD. For example, Hull and colleagues [6] found that the 3 most common reasons for hospitalization of patients with BPD were anorexia nervosa, psychotic symptoms, and suicidality—all of which are associated with frequent hospitalizations, in general. Compared with those without BPD, Zanarini and colleagues [7] found that inpatients with BPD had significantly more extensive histories of mental health treatment. Hurt [8] determined that hospital readmissions were most often associated with an Axis II diagnosis of BPD. Finally, in the Collaborative Longitudinal Study of Personality Disorders [9], investigators found that BPD in combination with posttraumatic stress disorder resulted in higher frequencies of hospitalization than those patients with BPD without this secondary diagnosis. 1.3. Self-harm behavior While DSM-IV [1] includes a criterion for recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior, an emerging body of literature is beginning to characterize the nuances of self-harm behavior. For example, compared with non-BPD controls, studies indicate that those with BPD evidence a greater number of suicide attempts [10] and [11], nonmedically serious attempts [12], serious overdoses [13], suicide attempts that are coupled with a history of self-mutilation [14], and suicidal behavior in the context of childhood sexual abuse [15]. In the Collaborative Longitudinal Personality Disorders Study [11], investigators determined in a sample of personality-disordered patients that BPD was a predictor for suicide attempts. Beyond the suicidal spectrum, the clinical relevance of global self-harm behavior to BPD was highlighted by Sansone and colleagues [16] who found that high scores on a self-harm measure were highly suggestive of the diagnosis of BPD. 1.4. Polysymptomatic presentations Several investigators have noted a relationship between BPD and multiple psychiatric symptoms. In this regard, Zweig-Frank and Paris [17], as well as Morey and Zanarini [18], describe high levels of neuroticism among patients with BPD. In addition, Zanarini and colleagues [19] found an association between BPD and multiple Axis I disorders and concluded that a lifetime pattern of complex psychiatric comorbidity has strong predictive power for the borderline diagnosis. The association between BPD and multiple Axis I diagnoses was also confirmed by Zimmerman and Mattia [20]. Soderberg [21] found an association between BPD and multiple Axis II disorders, which according to Becker and colleagues [22] is likely to include other Cluster B disorders. The finding of multiple Axis I and II disorders was also confirmed by the Collaborative Longitudinal Personality Disorders Study [23]. 1.5. Summary To summarize, a large body of empirical literature indicates that certain clinical features (eg, childhood abuse, high mental healthcare utilization, high levels of self-harm behavior, multiple Axis I and II diagnoses) are common among those with BPD. However, only 1 prior study has examined all 4 of these variables in a single study population. This is an important undertaking because perhaps only particular features emerge in certain BPD populations such as those in tertiary care facilities, inpatients vs outpatients, unique populations (ie, those who are incarcerated), or patients in specialty clinics (eg, eating disorders, substance abuse). The purpose of this study was to simultaneously examine, in a population of psychiatric inpatients, these 4 variables and their relationship to BPD—that is, to confirm, or not, their correlation with the BPD diagnosis.

3. Results The 2 groups were compared on number of types of traumatic events experienced in childhood, healthcare utilization (ie, number of hospitalizations for mental health or substance abuse, days in hospital for mental health or substance abuse, psychiatrists ever seen, therapists ever seen, courses of therapy, days in hospital for medical treatment, times in day treatment, days in day treatment), SHI score, and number of Axis I diagnoses at discharge. Table 1 presents the results of these group comparisons. The analyses showed that those in the BPD group scored significantly higher on the number of types of childhood traumas experienced, number of times hospitalized for mental health or substance abuse, days in hospital for mental health or substance abuse, number of psychiatrists ever seen, number of therapists ever seen, number of courses of therapy, and SHI score than did the non-BPD group. Although not significant, the BPD group reported more days in hospital for medical treatment, times in day treatment, and number of Axis I diagnoses at discharge than did the non-BPD group. Table 1. Study variables by BPD diagnosis (N = 97) Mental health variable Non-BPD (n = 66) BPD (n = 31) t-test value Number of types of trauma experienced 157 (1.23) 2.46 (1.62) −2.86** Number of days in hospital for mental health or substance abuse 22.97 (65.37) 66.18 (79.47) −2.72** Number of psychiatrists ever seen 2.52 (2.53) 4.53 (4.01) −2.94** Number of therapists ever seen 2.73 (4.57) 4.80 (4.52) −2.05* Number of courses of therapy 3.14 (5.66) 11.12 (21.90) −2.60* Number of days in hospital for medical treatment related to mental health or substance abuse 6.73 (1.00) 16.19 (41.65) −1.58 Number of times in day treatment 0.97 (2.60) 1.00 (1.31) −0.063 Number of days in day treatment 23.68 (84.22) 11.20 (31.33) 0.719 Total Self-Harm Inventory score 5.23 (3.93) 10.19 (3.83) −5.90*** Number of Axis I diagnoses at discharge 2.18 (1.12) 2.53 (1.24) −1.40 * P < .05. ** P < .01. *** P < .001.