Associated Features of Borderline Personality Disorder
Borderline Personality Disorder (BPD) is highly comorbid with other personality disorders, as well as with a number of Axis I disorders, most notably depression, anxiety, eating disorders, posttraumatic stress disorder, and substance abuse (Zanarini et al. 1998). Zanarini and colleagues (Zanarini et al. 1998) found that BPD could be depicted by a pattern of what she called complex comorbidity, characterized by multiple comorbid diagnoses that included both internalizing and externalizing disorders. Recent research has found that up to 84% of patients with BPD meet criteria for having one or more Axis I disorders within a 12-month period (Lenzenweger et al., 2007; Grant et al., 2008). A large epidemiological study (N = 34,653) found that, of individuals with BPD, 60% also meet criteria for an anxiety disorder, 50% meet criteria for a mood disorder, and 51% meet criteria for substance abuse (Grant et al., 2008). Consistent with these findings, Grilo and colleagues (Grilo et al. 1997) found that 86% of individuals who met criteria for major depression and substance abuse were comorbid for BPD. This is particularly problematic for the prognosis of comorbid mental health conditions. BPD has widely been found to interfere with the recovery process when comorbid Axis I disorders are the focus of treatment (Clarkin 2006; Newton-Howes et al., 2006; Skodol et al., 2002).
Many individuals with BPD report having suffered negative childhood events, such as trauma, abuse, or neglect. Such experiences are hypothesized to interact with genetic or biological factors in the development of borderline personality disorder (See page on the Etiology of BPD). Post-traumatic stress disorder is common, but not universal, among patients with BPD (Leichsenring et al., 2011). Adults with borderline personality disorder also tend to experience adverse events at a higher rate than those without the disorder; patients with BPD have been found to be significantly more likely to have an abusive partner, to have been raped, and to have been physically and/or sexually assaulted (Zanarini, Frankenburg, Reich, et al., 1999).
Functional impairment is an important consideration in the assessment and treatment of BPD. Problematic interpersonal functioning is an inherent feature of the disorder, as reflected in several of the DSM diagnostic criteria. Functional impairment – which varies in form and degree among patients with BPD – may stem from maladaptive behavioural responses to inordinate psychological pain (Zanarini & Frankenburg, 2007). Research has demonstrated that adults with BPD consistently have the most severe functional impairment compared to adults diagnosed with other personality disorders and mood disorders (Jackson, Burgess, 2000; Skodol, Gunderson, McGlasahn, et al., 2002, Zanarini, Frankenburg, Hennen, & Silk, 2005). This severe functional impairment has also been found in adolescents diagnosed with BPD (Chanen, Jovel, & Jackson, 2007).
Vocational functioning is a prominent area of difficulty for many individuals with borderline personality disorder. Empirical studies have demonstrated that over 50% of those diagnosed with BPD are unemployed and severely impaired vocationally (Elliott & Weissenborn, 2010). Vocational impairment has been demonstrated to be strongly associated with impulsivity in BPD (Sio, Chanen, Killackey, & Gleeson, 2011). In contrast to other BPD features, impulsivity has been proposed as an important factor impeding individuals diagnosed with BPD to meet their social, academic, and occupational obligations (Bagge, Nickell, Stepp, Durrett, Jackson, & Trull, 2004).