The relationship of chronic medical illnesses, poor health-related lifestyle choices, and health care utilization to recovery status in borderline patients over a decade of prospective follow-up

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Abstract

Background

The interaction of borderline personality disorder (BPD) with physical health has not been well characterized. In this longitudinal study, we investigated the long-term relationship of chronic medical illnesses, health-related lifestyle choices, and health services utilization to recovery status in borderline patients over a decade of prospective follow-up.

Method

264 borderline patients were interviewed concerning their physical health at 6-year follow-up in a longitudinal study of the course of BPD. This sample was then reinterviewed five times at two-year intervals over the next ten years. We defined recovery from BPD based on a Global Assessment of Functioning score of 61 or higher, which required BPD remission, one close relationship, and full-time competent and consistent work or school attendance. We controlled for potentially confounding effects of time-varying major depressive disorder.

Results

Never-recovered borderline patients were significantly more likely than ever-recovered borderline patients to have a medical syndrome, obesity, osteoarthritis, diabetes, urinary incontinence, or multiple medical conditions (p < 0.0063). They were also significantly more likely to report pack-per-day smoking, weekly alcohol use, no regular exercise, daily sleep medication use, or pain medication overuse (p < 0.0083). In addition, never-recovered borderline patients were significantly more likely than ever-recovered borderline patients to undergo a medical emergency room visit, medical hospitalization, X-ray, CT scan, or MRI scan (p < 0.0063).

Conclusions

Over a decade of prospective follow-up, failure to recover from BPD seems to be associated with a heightened risk of chronic medical illnesses, poor health-related lifestyle choices, and costly health services utilization.

Introduction

Little is known about the relationship between borderline personality disorder and physical illness. Few studies have attempted to characterize the association of borderline personality disorder with medical co-morbidities and health care utilization. One early study showed a relationship between symptoms of borderline personality disorder and obesity (Sansone et al., 2001). A recent study found a significant relationship between the presence of borderline personality disorder and higher rates of arteriosclerosis, arthritis, cardiovascular disease, gastrointestinal disease, hypertension, liver disease, venereal disease, and “any assessed medical condition” (El-Gabalawy et al., 2010). Previous research has also reported correlations between the presence of borderline personality disorder and use of higher numbers of primary care physicians and medical specialists (Sansone et al., 2011), as well as increased utilization of medical office visits (Ansell et al., 2007, Sansone et al., 1996, Sansone et al., 1998), telephone calls to medical offices (Sansone et al., 1998), medication prescriptions (Sansone et al., 1996, Sansone et al., 1998), emergency room visits (Black et al., 2006), and inpatient hospitalizations (Black et al., 2006). Another recent study of adults between 55 and 64 years of age found that the number of BPD features predicts negative health perceptions, decreased physical functioning, more role limitations and more pain at baseline, as well as more negative health perceptions, lower energy, higher health care utilization, and more medication usage six months later (Powers & Oltmanns, 2012).

In 2004, we published the first study to examine medical health in a well-diagnosed sample of remitted and non-remitted borderline patients (Frankenburg and Zanarini, 2004). We found that non-remitted borderline patients were more likely than remitted patients to have a syndrome-like medical condition, specifically chronic fatigue, fibromyalgia, or temporomandibular joint syndrome (TMJ). Borderline patients who had not achieved remission also had a higher prevalence of certain chronic medical conditions, particularly back pain, diabetes, hypertension, obesity, osteoarthritis, and urinary incontinence. In addition, we observed that non-remitted borderline patients more often reported poor self-care in the form of pack-per-day smoking, daily alcohol use, daily sleep medication use, lack of regular exercise, and overuse of pain medications. Finally, non-remitted borderline patients were more likely to undergo a medically-related emergency room visit, a medical hospitalization, or both.

The current study is the first to describe the long-term longitudinal course of chronic medical illnesses, health-related lifestyle choices, and utilization of health care services in borderline patients. Specifically, we assessed the relationship of these medical variables among patients who recovered from BPD versus borderline patients who never recovered over a decade of prospective follow-up. Given existing evidence for a relationship between major depressive disorder (MDD) and higher rates of both general medical illness and increased health services utilization, (Druss et al., 2000, Katon, 2003, Simon et al., 1995a, Simon et al., 1995b) we also controlled for potential confounding effects of time-varying MDD on participants’ physical health, health-related self-care, and health care utilization. This extends our initial cross-sectional design that compared non-remitted borderline patients with remitted borderline patients. We hypothesized that patients who never recovered from BPD would be more likely than borderline patients who recovered to have a poorly defined medical syndrome or other chronic medical condition over ten years of follow-up. We also hypothesized that patients who never recovered from BPD would be more likely to make poor health-related lifestyle choices than borderline patients who recovered over a decade of follow-up. Additionally, we hypothesized that patients who never recovered from BPD would be more likely to utilize costly medical services than borderline patients who recovered over a prospectively observed period of ten years. Finally, we hypothesized that patients who never recovered from BPD would be more likely to face financial challenges related to their health status than borderline patients who recovered over a decade of follow-up.

Section snippets

Methods

The current study is part of a multifaceted longitudinal study of the course of borderline personality disorder – the McLean Study of Adult Development (MSAD). The methodology of this study, which was reviewed and approved by the McLean Hospital Institutional Review Board, has been described in detail elsewhere (Zanarini et al., 2003). Briefly, all patients were initially inpatients at McLean Hospital in Belmont, Mass. Each patient was screened to determine that he or she was 18–35 years of

Results

Briefly, there were two hundred and sixty-four borderline patients at 6-year follow-up. Among borderline participants at 6-year follow-up, 80.7% (N = 213) were women and 87.5% (N = 231) were white. Their average age was 33.0 years (SD = 5.9) and the mean socioeconomic status was 3.4 (SD = 1.4) (where 1 = highest and 5 = lowest) (Hollingshead, 1957). Borderline participants at 6-year follow-up had a mean GAF score of 54.2 (SD = 13.2), indicating moderate symptoms or moderate difficulty in social,

Discussion

This study is the first to examine the long-term longitudinal relationship of borderline personality disorder in well-diagnosed patients to chronic medical illness, poor health-related lifestyle choices, costly health care service utilization, and financial challenges related to medical illness. Our study contributes to the literature by reporting longitudinal differences in these medically-related variables based on recovery status among borderline patients over a decade of prospective

Conflict of interest

All authors declare that they do not have any conflicts of interest.

Contributors

Mary C. Zanarini designed the study and wrote the protocol. Alex S. Keuroghlian managed the literature searches, undertook the statistical analysis, and wrote the first draft of the manuscript. Frances R. Frankenburg and Mary C. Zanarini contributed to the writing of the manuscript. All authors have approved the final manuscript.

Role of funding source

This study was supported by the National Institute of Mental Health (NIMH) grants MH47588 and MH62169 (PI: Mary C. Zanarini, Ed.D.). The source of funding had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Acknowledgments

We would like to thank the patients who participated in this study. We thank Dr. Garrett Fitzmaurice, Sc.D., Director of the Laboratory of Psychiatric Biostatistics at McLean Hospital, for his statistical assistance. We also thank Joseph Lewko, of the Laboratory for Study of Adult Development at McLean Hospital, for his assistance with data management.

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