Christine Bergel presents a fairly classic history for bulimia nervosa (BN). Like 90% of patients with BN, Ms. Hoffman is female, and, as is usual, her symptoms began when she was in her late teens or early 20s. One reason for this age at onset is the stress of entering college or the workforce. Genetics and environment also play a role, but it is not entirely clear why certain young people develop BN while others do not, despite equivalent amounts of body dissatisfaction.
The hallmark of the illness is binge eating, which is usually defined as eating an inappropriately large amount of food in a discrete period of time (e.g., at a meal), in conjunction with a sense of loss of control while eating. Although food portions are typically large in BN, the predominant feature for many people is the sense of loss of control.
Along with the binge eating, the vast majority of patients engage in self-induced vomiting. This behavior usually begins out of fear that the binge eating will result in weight gain, with the subsequent vomiting seen as a way of eliminating this risk. Early in the course of the illness, most patients induce vomiting with their fingers, but they often develop the capacity to vomit at will. Some patients with BN may also use laxatives to induce diarrhea; this method may induce a sense of weight loss, but laxatives are actually more effective at inducing dehydration, with its accompanying physical symptoms and medical risk. Some individuals with BN also use diuretics, and many experiment with diet pills.
Most people with BN tend to seek help because of complications of the disorder rather than dissatisfaction with the eating behavior. For example, medical complications commonly include dehydration and electrolyte abnormalities, particularly hypochloremia and metabolic alkalosis, and, more rarely, hypokalemia. These complications can lead to feelings of fatigue, headache, and poor concentration. Rare but serious medical complications include gastric dilatation and esophageal rupture.
Although Ms. Hoffman sought help from a psychiatrist, she did so through her internist, and it is common for people with BN to present to their primary care physicians with vague medical complaints. Interestingly, the health practitioners who are often in the best position to identify patients with BN are dentists, who find evidence of obvious enamel erosion.
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
- A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
- Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
- The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
- Self-evaluation is unduly influenced by body shape and weight.
- The disturbance does not occur exclusively during episodes of anorexia nervosa.
- In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time.
- In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time.
Specify current severity:
The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability.
- Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week.
- Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per week.
- Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per week.
- Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.
There are three essential features of bulimia nervosa: recurrent episodes of binge eating (Criterion A), recurrent inappropriate compensatory behaviors to prevent weight gain (Criterion B), and self-evaluation that is unduly influenced by body shape and weight (Criterion D). To qualify for the diagnosis, the binge eating and inappropriate compensatory behaviors must occur, on average, at least once per week for 3 months (Criterion C).
An “episode of binge eating” is defined as eating, in a discrete period of time, an amount of food that is definitely larger than most individuals would eat in a similar period of time under similar circumstances (Criterion A1). The context in which the eating occurs may affect the clinician’s estimation of whether the intake is excessive. For example, a quantity of food that might be regarded as excessive for a typical meal might be considered normal during a celebration or holiday meal. A “discrete period of time” refers to a limited period, usually less than 2 hours. A single episode of binge eating need not be restricted to one setting. For example, an individual may begin a binge in a restaurant and then continue to eat on returning home. Continual snacking on small amounts of food throughout the day would not be considered an eating binge.
An occurrence of excessive food consumption must be accompanied by a sense of lack of control (Criterion A2) to be considered an episode of binge eating. An indicator of loss of control is the inability to refrain from eating or to stop eating once started. Some individuals describe a dissociative quality during, or following, the binge-eating episodes. The impairment in control associated with binge eating may not be absolute; for example, an individual may continue binge eating while the telephone is ringing but will cease if a roommate or spouse unexpectedly enters the room. Some individuals report that their binge-eating episodes are no longer characterized by an acute feeling of loss of control but rather by a more generalized pattern of uncontrolled eating. If individuals report that they have abandoned efforts to control their eating, loss of control should be considered as present. Binge eating can also be planned in some instances.
The type of food consumed during binges varies both across individuals and for a given individual. Binge eating appears to be characterized more by an abnormality in the amount of food consumed than by a craving for a specific nutrient. However, during binges, individuals tend to eat foods they would otherwise avoid.
Individuals with bulimia nervosa are typically ashamed of their eating problems and attempt to conceal their symptoms. Binge eating usually occurs in secrecy or as inconspicuously as possible. The binge eating often continues until the individual is uncomfortably, or even painfully, full. The most common antecedent of binge eating is negative affect(Cardi et al. 2015). Other triggers include interpersonal stressors; dietary restraint; negative feelings related to body weight, body shape, and food; and boredom. Binge eating may minimize or mitigate factors that precipitated the episode in the short-term, but negative self-evaluation and dysphoria often are the delayed consequences.
Another essential feature of bulimia nervosa is the recurrent use of inappropriate compensatory behaviors to prevent weight gain (Criterion B). Many individuals with bulimia nervosa employ several methods to compensate for binge eating. Self-induced vomiting, a type of purging behavior, is the most common inappropriate compensatory behavior. The immediate effects of vomiting include relief from physical discomfort and reduction of fear of gaining weight. In some cases, vomiting becomes a goal in itself, and the individual will binge eat in order to vomit or will vomit after eating a small amount of food. Individuals with bulimia nervosa may use a variety of methods to induce vomiting, including the use of fingers or instruments to stimulate the gag reflex. Individuals generally become adept at inducing vomiting and are eventually able to vomit at will. Rarely, individuals consume syrup of ipecac to induce vomiting. Other purging behaviors include the misuse of laxatives and diuretics(Mitchell and Crow 2006) and, in rare cases, the misuse of enemas following episodes of binge eating, although this is seldom the sole compensatory method employed. A number of compensatory methods other than purging may also be used in rare cases. Some individuals may take thyroid hormone in an attempt to avoid weight gain. Individuals with diabetes mellitus and bulimia nervosa may omit or reduce insulin doses in order to reduce the metabolism of food consumed during eating binges. Individuals with bulimia nervosa may fast for a day or more or exercise excessively in an attempt to prevent weight gain. Exercise may be considered excessive when it significantly interferes with important activities, when it occurs at inappropriate times or in inappropriate settings, or when the individual continues to exercise despite injury or other medical complications.
Individuals with bulimia nervosa place an excessive emphasis on body shape or weight in their self-evaluation, and these factors are typically extremely important in determining self-esteem (Criterion D)(Levinson et al. 2017). Individuals with this disorder may closely resemble those with anorexia nervosa in their fear of gaining weight, in their desire to lose weight, and in the level of dissatisfaction with their bodies. However, a diagnosis of bulimia nervosa should not be given when the disturbance occurs only during episodes of anorexia nervosa (Criterion E).
Individuals with bulimia nervosa typically are within the normal weight or overweight range (body mass index [BMI] ≥ 18.5 and < 30 in adults). The disorder occurs but is uncommon among obese individuals. Between eating binges, individuals with bulimia nervosa typically restrict their total caloric consumption and preferentially select low-calorie (“diet”) foods while avoiding foods that they perceive to be fattening or likely to trigger a binge.
Menstrual irregularity or amenorrhea often occurs among females with bulimia nervosa; it is uncertain whether such disturbances are related to weight fluctuations, to nutritional deficiencies, or to emotional distress. The fluid and electrolyte disturbances resulting from the purging behavior are sometimes sufficiently severe to constitute medically serious problems. Rare but potentially fatal complications include esophageal tears, gastric rupture, and cardiac arrhythmias. Serious cardiac and skeletal myopathies have been reported among individuals following repeated use of syrup of ipecac to induce vomiting. Individuals who chronically abuse laxatives may become dependent on their use to stimulate bowel movements. Gastrointestinal symptoms are commonly associated with bulimia nervosa, and rectal prolapse has also been reported among individuals with this disorder(Kress et al. 2018; Mitchell and Crow 2006).
According to two U.S. epidemiological studies conducted in adult community samples(Hudson et al. 2007; Udo and Grilo 2018), the 12-month prevalence of bulimia nervosa ranges from 0.14% to 0.3%, with much higher rates in women than in men (0.22% to 0.5% in women; 0.05% to 0.1% in men), and the lifetime prevalence ranges from 0.28% to 1.0% (0.46% to 1.5% in women; 0.05% to 0.08% in men). In one study of adolescents ages 13–18, lifetime prevalence rates were 1.3% and 0.5% in girls and boys, respectively(Swanson et al. 2011).
In the United States, the prevalence of bulimia nervosa is similar across U.S. ethnoracial groups(Marques et al. 2011; Pike et al. 2014; Udo and Grilo 2018). The reported prevalence of bulimia nervosa is highest in populations residing in high-income industrialized countries, such as the United States, Canada, Australia, New Zealand, and many European countries; in most of these countries the prevalence of bulimia nervosa is roughly comparable.
The prevalence of bulimia nervosa in some regions of Latin America and the Middle East is similar to the prevalence in most high-income countries(Institute for Health Metrics and Evaluation 2019; Kessler et al. 2013; Kolar et al. 2016). The prevalence of bulimia nervosa appears to be gradually increasing in many low- and middle-income countries.
Development and Course
Bulimia nervosa commonly begins in adolescence or young adulthood(Hoek et al. 1995; Hudson et al. 2007; Striegel-Moore et al. 2003; Wade 2019). Onset before puberty or after age 40 is uncommon. The binge eating frequently begins during or after an episode of dieting to lose weight. Experiencing multiple stressful life events also can precipitate onset of bulimia nervosa.
Disturbed eating behavior persists for at least several years in a high percentage of clinical samples. The course may be chronic or intermittent, with periods of remission alternating with recurrences of binge eating. However, over longer-term follow-up, the symptoms of many individuals appear to diminish with or without treatment, although treatment clearly impacts outcome. Periods of remission longer than 1 year are associated with better long-term outcome.
Significantly elevated risk for mortality (all-cause and suicide) has been reported for individuals with bulimia nervosa(Keel and Brown 2010; Preti et al. 2011; Steinhausen and Weber 2009; van Son et al. 2010). The crude mortality rate (ratio of the number of deaths during the year to the average population in that year) for bulimia nervosa is nearly 2% per decade(Arcelus et al. 2011; Smink et al. 2012).
Diagnostic crossover from initial bulimia nervosa to anorexia nervosa occurs in a minority of cases (10%–15%). Individuals who do experience crossover to anorexia nervosa commonly will revert back to bulimia nervosa or have multiple occurrences of crossovers between these disorders. A subset of individuals with bulimia nervosa continue to binge eat but no longer engage in inappropriate compensatory behaviors, and therefore their symptoms meet criteria for binge-eating disorder or other specified eating disorder. Diagnosis should be based on the current (i.e., past 3 months) clinical presentation.
Risk and Prognostic Factors
Weight concerns, low self-esteem, depressive symptoms, social anxiety disorder, and childhood generalized anxiety disorder are associated with increased risk for the development of bulimia nervosa.
Internalization of a thin body ideal has been found to increase risk for developing weight concerns, which in turn increases risk for the development of bulimia nervosa. Individuals who experienced childhood sexual or physical abuse are at increased risk for developing bulimia nervosa.
Genetic and physiological
Childhood obesity and early pubertal maturation increase risk for bulimia nervosa. Familial transmission of bulimia nervosa may be present, as well as genetic vulnerabilities for the disorder(Bulik et al. 2019; Himmerich et al. 2019; Jacobi et al. 2004; Striegel-Moore and Bulik 2007).
Severity of psychiatric comorbidity predicts worse long-term outcome of bulimia nervosa(Keel and Brown 2010).
Culture-Related Diagnostic Issues
Although data show that community-based prevalence of bulimia nervosa does not differ significantly across U.S. ethnoracial groups(Udo and Grilo 2018), treatment utilization for bulimia nervosa is lower among underserved U.S. ethnic and racialized groups than among the non-Latinx White population(Marques et al. 2011).
Sex- and Gender-Related Diagnostic Issues
Bulimia nervosa is much more common in girls and women than in boys and men. Boys and men are especially underrepresented in treatment-seeking samples, for reasons that have not yet been systematically examined(Striegel-Moore et al. 2000; Swanson et al. 2011).
No specific diagnostic test for bulimia nervosa currently exists(Striegel et al. 2012). However, several laboratory abnormalities may occur as a consequence of purging and may increase diagnostic certainty. These include fluid and electrolyte abnormalities, such as hypokalemia (which can provoke cardiac arrhythmias), hypochloremia, and hyponatremia. The loss of gastric acid through vomiting may produce a metabolic alkalosis (elevated serum bicarbonate), and the frequent induction of diarrhea or dehydration through laxative and diuretic abuse can cause metabolic acidosis. Some individuals with bulimia nervosa exhibit mildly elevated levels of serum amylase, probably reflecting an increase in the salivary isoenzyme.
Physical examination usually yields no physical findings. However, inspection of the mouth may reveal significant and permanent loss of dental enamel, especially from lingual surfaces of the front teeth because of recurrent vomiting. These teeth may become chipped and appear ragged and “moth-eaten.” There may also be an increased frequency of dental caries. In some individuals, the salivary glands, particularly the parotid glands, may become notably enlarged. Individuals who induce vomiting by manually stimulating the gag reflex may develop calluses or scars on the dorsal surface of the hand from repeated contact with the teeth. Serious cardiac and skeletal myopathies have been reported among individuals following repeated use of syrup of ipecac to induce vomiting.
Association With Suicidal Thoughts or Behavior
Suicide risk is elevated in bulimia nervosa(Crow et al. 2009; Franko and Keel 2006; Goldstein and Gvion 2019; Wade 2019). A review found that approximately one-quarter to one-third of individuals with bulimia nervosa have had suicidal ideation, and a similar proportion have attempted suicide(Smith et al. 2018).
Functional Consequences of Bulimia Nervosa
Individuals with bulimia nervosa may exhibit a range of functional limitations associated with the disorder and have reduced health-related quality of life(Winkler et al. 2014). A minority of individuals report severe role impairment, with the social-life domain most likely to be adversely affected by bulimia nervosa.
Borderline Personality Disorder
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
- Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
- Identity disturbance: markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
- Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
The essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.
Individuals with borderline personality disorder make frantic efforts to avoid real or imagined abandonment (Criterion 1). The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, affect, cognition, and behavior. These individuals are very sensitive to environmental circumstances. They experience intense abandonment fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans (e.g., sudden despair in reaction to a clinician’s announcing the end of the hour; panic or fury when someone important to them is just a few minutes late or must cancel an appointment). They may believe that this “abandonment” implies they are “bad.” These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors, which are described separately in Criterion 5 (see also “Association With Suicidal Thoughts or Behavior”).
Individuals with borderline personality disorder have a pattern of unstable and intense relationships (Criterion 2). They may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, or is not “there” enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will “be there” in return to meet their own needs on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternatively be seen as beneficent supports or as cruelly punitive. Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected.
There may be an identity disturbance characterized by markedly and persistently unstable self-image or sense of self (Criterion 3). There are sudden and dramatic shifts in self-image (e.g., suddenly changing from the role of a needy supplicant for help to that of a righteous avenger of past mistreatment). Although they usually have a self-image that is based on the feeling of being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all. This can be both painful and frightening to those with this disorder. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing, and support. These individuals may show worse performance in unstructured work or school situations. This lack of a full and enduring identity makes it difficult for the individual with borderline personality disorder to identify maladaptive patterns of behavior and can lead to repetitive patterns of troubled relationships.
Individuals with borderline personality disorder display impulsivity in at least two areas that are potentially self-damaging (Criterion 4). They may gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly. Individuals with this disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior (Criterion 5). Recurrent suicidal thoughts or behavior are often the reason that these individuals present for help. These self-destructive acts are usually precipitated by threats of separation or rejection or by expectations that the individual assume increased responsibility. Self-mutilative acts (e.g., cutting or burning) are very common and may occur during periods in which the individual is experiencing dissociative symptoms. These acts often bring relief by reaffirming the individual’s ability to feel or by expiating the individual’s sense of being evil.
Individuals with borderline personality disorder may display affective instability that is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) (Criterion 6). The basic dysphoric mood of those with borderline personality disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satisfaction. These episodes may reflect the individual’s extreme reactivity to interpersonal stresses.
Individuals with borderline personality disorder may be troubled by chronic feelings of emptiness, which can co-occur with painful feelings of aloneness (Criterion 7). Easily bored, they may frequently seek excitement to avoid their feelings of emptiness.
Individuals with this disorder frequently express inappropriate, intense anger or have difficulty controlling their anger (Criterion 8). They may display extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often followed by shame and guilt and contribute to the feeling they have of being evil.
During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur (Criterion 9), but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in response to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The real or perceived return of the caregiver’s nurturance may result in a remission of symptoms.
Individuals with borderline personality disorder may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; destroying a good relationship just when it is clear that the relationship could last). Some individuals develop psychotic-like symptoms (e.g., hallucinations, body-image distortions, ideas of reference, hypnagogic phenomena) during times of stress. Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships. Premature death from suicide may occur in individuals with borderline personality disorder, especially in those with co-occurring depressive disorders or substance use disorders. However, deaths from other causes. such as accidents or illness, are more than twice as common as deaths by suicide in individuals with borderline personality disorder(Temes et al. 2019). Physical handicaps may result from self-inflicted abuse behaviors or failed suicide attempts. Recurrent job losses, interrupted education, and separation or divorce are common. Physical and sexual abuse, neglect, hostile conflict, and early parental loss are more common in the childhood histories of those with borderline personality disorder.
The estimated prevalence of borderline personality disorder based on a probability subsample from Part II of the National Comorbidity Survey Replication was 1.4%(Lenzenweger et al. 2007). The prevalence of borderline personality disorder in the National Epidemiologic Survey on Alcohol and Related Conditions data was 5.9%(Grant et al. 2008). A review of seven epidemiological studies (six in the United States) found a median prevalence of 2.7%(Morgan and Zimmerman 2018). The prevalence of borderline personality disorder is about 6% in primary care settings(Gross et al. 2002), about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients(Widiger and Frances 1989; Zimmerman et al. 2017).
Development and Course
Borderline personality disorder has typically been thought of as an adult-onset disorder. However, it has been found in treatment settings that symptoms in adolescents as young as age 12 or 13 years can meet full criteria for the disorder(Ha et al. 2014; Kaess et al. 2013; Zanarini et al. 2017). It is not yet known what percentage of adults first entering treatment actually have such an early onset of borderline personality disorder.
Borderline personality disorder has long been thought of as a disorder with a poor symptomatic course, which tended to lessen in severity as those with borderline personality disorder entered their 30s and 40s. However, prospective follow-up studies have found that stable remissions of 1–8 years are very common(Gunderson et al. 2011; Zanarini et al. 2012). Impulsive symptoms of borderline personality disorder remit the most rapidly, while affective symptoms remit at a substantially slower rate(Zanarini et al. 2016). In contrast, recovery from borderline personality disorder (i.e., concurrent symptomatic remission and good psychosocial functioning) is more difficult to achieve and less stable over time(Zanarini et al. 2012). Lack of recovery is associated with supporting oneself on disability benefits and suffering from poor physical health(Keuroghlian et al. 2013).
Risk and Prognostic Factors
Borderline personality disorder has also been found to be associated with high rates of various forms of reported childhood abuse and emotional neglect(Zanarini et al. 1997). However, reported rates of sexual abuse are higher in inpatients than in outpatients with this disorder, suggesting that a history of sexual abuse is as much a risk factor for severity of borderline psychopathology as it is for the disorder itself. In addition, an empirically based consensus has arisen that suggests that a childhood history of reported sexual abuse is neither necessary nor sufficient for the development of borderline personality disorder.
Genetic and physiological
Borderline personality disorder is about five times more common among first-degree biological relatives of those with the disorder than in the general population. There is also an increased familial risk for substance use disorders, anxiety disorders, antisocial personality disorder, and depressive or bipolar disorders.
Culture-Related Diagnostic Issues
The pattern of behavior seen in borderline personality disorder has been identified in many settings around the world. Sociocultural contexts characterized by social demands that evoke attempts at self-affirmation and acceptance by others, ambiguous or conflictual relationships with authority figures, or marked uncertainties in adaptation can foster impulsivity, emotional instability, explosive or aggressive behaviors, and dissociative experiences that are associated with borderline personality disorder or with transient and contextual reactions to those environments that can be confused with borderline personality disorder(Narayanan and Rao 2018; Paris and Lis 2013). Given that psychodynamic, cognitive, behavioral, and mindfulness aspects of models of mind and self vary cross-culturally(Hsu and Tseng 1969; Tseng 2001), symptoms or traits that suggest the presence of borderline personality disorder (e.g., number of sexual partners, shifting between relationships, substance use)(Narayanan and Rao 2018; Wang et al. 2012) must be evaluated in light of cultural norms to make a valid diagnosis.
Sex- and Gender-Related Diagnostic Issues
While borderline personality disorder is more common among women than men in clinical samples, community samples demonstrate no difference in prevalence between men and women(Bayes and Parker 2017; Grant et al. 2008). This discrepancy may reflect a higher degree of help-seeking among women, leading them to clinical settings. Clinical characteristics of men and women with borderline personality disorder appear to be similar, with potentially a higher degree of externalizing behaviors in boys and men and internalizing behaviors in girls and women(Bayes and Parker 2017).
Association With Suicidal Thoughts or Behavior
ln a longitudinal study, impulsive and antisocial behaviors of individuals with borderline personality disorder were associated with increased suicide risk(Soloff and Chiappetta 2012). In a sample of hospitalized patients with borderline personality disorder followed prospectively for 24 years, around 6% died by suicide, compared with 1.4% in a comparison sample of individuals with personality disorders other than borderline personality disorder(Temes et al. 2019). A study of individuals with borderline personality disorder followed for 10 years found that recurrent suicidal behavior was a defining characteristic of borderline personality disorder, associated with declining rates of suicide attempts from 79% to 13% over time(Zanarini et al. 2008).
Depressive and bipolar disorders
Borderline personality disorder often co-occurs with depressive or bipolar disorders, and when criteria for both are met, both should be diagnosed. Because the cross-sectional presentation of borderline personality disorder can be mimicked by an episode of depressive or bipolar disorder, the clinician should avoid giving an additional diagnosis of borderline personality disorder based only on cross-sectional presentation without having documented that the pattern of behavior had an early onset and a long-standing course.
Separation anxiety disorder in adults
Separation anxiety disorder and borderline personality disorder are characterized by fear of abandonment by loved ones, but problems in identity, self-direction, interpersonal functioning, and impulsivity are additionally central to borderline personality disorder.
Other personality disorders
Other personality disorders may be confused with borderline personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to borderline personality disorder, all can be diagnosed. Although histrionic personality disorder can also be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, borderline personality disorder is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness. Paranoid ideas or illusions may be present in both borderline personality disorder and schizotypal personality disorder, but these symptoms are more transient, interpersonally reactive, and responsive to external structuring in borderline personality disorder. Although paranoid personality disorder and narcissistic personality disorder may also be characterized by an angry reaction to minor stimuli, the relative stability of self-image, as well as the relative lack of physical self-destructiveness, repetitive impulsivity, and profound abandonment concerns, distinguishes these disorders from borderline personality disorder. Although antisocial personality disorder and borderline personality disorder are both characterized by manipulative behavior, individuals with antisocial personality disorder are manipulative to gain profit, power, or some other material gratification, whereas the goal in borderline personality disorder is directed more toward gaining the concern of caretakers. Both dependent personality disorder and borderline personality disorder are characterized by fear of abandonment; however, the individual with borderline personality disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas the individual with dependent personality disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline personality disorder can further be distinguished from dependent personality disorder by the typical pattern of unstable and intense relationships.
Personality change due to another medical condition
Borderline personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are a direct physiological consequence of another medical condition.
Substance use disorders
Borderline personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.
Borderline personality disorder should be distinguished from an identity problem, which is reserved for identity concerns related to a developmental phase (e.g., adolescence) and does not qualify as a mental disorder. Adolescents and young adults with identity problems (especially when accompanied by substance use) may transiently display behaviors that misleadingly give the impression of borderline personality disorder. Such situations are characterized by emotional instability, existential dilemmas, uncertainty, anxiety-provoking choices, conflicts about sexual orientation, and competing social pressures to decide on careers.
Common co-occurring disorders include depressive and bipolar disorders, substance use disorders, anxiety disorders (particularly panic disorder and social anxiety disorder)(McGlashan et al. 2000; Zanarini et al. 2004), eating disorders (notably bulimia nervosa and binge-eating disorder)(Zanarini et al. 2010), posttraumatic stress disorder, and attention-deficit/hyperactivity disorder. Borderline personality disorder also frequently co-occurs with the other personality disorders.
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