Depersonalization disorder

INTRODUCTION

Substance abuse is extremely common in patients with borderline personality disorder (BPD), and reported prevalences range from 11 to 69% (1-6). Recent reports have focused on substance use patterns and preferences. Akiskal et al. (2) reported that outpatients with DSM-III BPD prefer alcohol and sedative-hypnotics. Dulit et al. (6) reported that inpatients with DSM-IN BPD prefer alcohol and sedatives but used, as well, cannabis, cocaine, opiates, and stimulants.

In this study we compared substance-using BPD patients with a sample of nonsubstance-using BPD patients on selected demographic, treatment, and outcome variables. We were interested specifically in documenting the impact of comorbid substance abuse on the patients' social and economic adjustment. In addition, we wanted to investigate the association of substance use with symptoms highly correlated in the literature with BPD, including chaotic sexuality (7), suicide gestures and attempts (8), and depersonalization and derealization (9).

METHOD

149 consecutively admitted patients given the discharge diagnosis of BPD were identified, representing 5.9% of 2,521 patients admitted to our hospital over a 26-month period. 14 charts were either unavailable (n = 10) or incomplete (n = 4). 31 charts were rejected because adequate documentation was lacking for five of eight DSM-RI criteria for BPD that are characteristic of the patient's long-term functioning. We were careful to exclude subthreshold cases having only three or four symptoms even if those symptoms were prominent and unequivocal. Six charts were excluded because the patients had a second Axis Ill diagnosis: schizotypal (n = 4) and antisocial (n = 2); and six charts were excluded because the patients had schizophrenia, casting some doubt on the BPD diagnoses. The remaining charts were further reviewed with a 99-item checklist and the DSM-III Again, for all diagnoses, convincing documentation of DSM-III criteria was required. With this method, 40 BPD patients without and 52 BPD patients with comorbid substance-abuse disorders were identified.

To establish the diagnostic reliability of the substance-abuse diagnoses, 15 randomly selected charts were reviewed blindly by two raters. The kappa values for DSM-III substance-abuse disorders were as follows: alcohol, 0. 85; sedative-hypnotic, 0.82; opiates, 1.00; cocaine, 0.85; and stimulants, 1.00. To further support the validity of our methodology, a randomly selected subgroup of 13 patients was interviewed to assess independently DSM-III substance-abuse diagnoses. The kappa values for DSM-III substance-abuse disorders were as follows: alcohol, 0.85; sedative-hypnotic, 0.85; and cocaine, 1.00.

This study used DSM-III rather than DSM-III-R diagnostic criteria. Only minimal changes were made in the diagnostic criteria for BPD in the DSM-RI-R, and these would not have changed the diagnosis of any subject in the study. Of note, Morey (10) has shown the DSM-III criteria for BPD identify virtually the same patients as DSM-III-R criteria (k = 0. 97). The changes from the DSM-III criteria to the DSM-III-R criteria for substance-abuse disorders were major, but nearly all of our subjects who met DSM-III criteria for substance abuse would now meet the criteria for DSM-III-R psychoactive substance dependence.

Statistical Analysis

BPD patients with and without substance-abuse disorders were compared across demographic, diagnostic, clinical, and outcome variables. Categorical data were compared using the chi-square statistic, and continuous data were compared using Student's t test.

RESULTS

The 52 substance-using patients had a mean ([+ or -] SD) age of 29 ([+ or -] 7) years, 73% were female, and 86% were White. The 40 nonsubstance using patients had a mean ([+ or -] SD) age of 29 ([+ or -] 6) years, 88% were female, and 85% were White. These differences were not significant.

Comparison of the index hospitalization revealed few differences between substance-using and nonsubstance-using BPD patients (see Table 1). There were no differences in number of prior psychiatric hospitalizations; length of stay of the index admission; episodes of violence, seclusion, or restraint; presence of psychotic symptoms; treatment with antidepressants or neuroleptics; episodes of medication refusal; or against medical advice discharges. Comorbid Axis I affective disorders were common in both groups and did not differentiate the groups.

[TABULAR DATA 1 OMITTED]

Among substance-using patients, drug choice correlated with gender. While 9 (64%) of 14 men used stimulants, only 11 (29%) of 38 women used stimulants [[chi].sup.2] (Yates) = 4.0, df = 1, p = .05]. Conversely, while alcohol and sedative-hypnotics were the drug of choice for 27 (71%) of the women, they were used by only 5 (36%) of the men [[chi].sup.2] (yates) = 4.0, df = 1, p = .05].

The social and economic impact of comorbid substance abuse on the BPD patients was profound. While 21 (52%) of 40 nonsubstance-using BPD patients were employed, only 5 (10%) of 52 substance-using patients were employed [[chi].sup.2] (Yates) = 18.5, df = 1, p = .0011. When comparing employment status at the level of skilled labor and professional and executive occupations, the difference was even more striking. While 12 (30%) of 40 nonsubstance-using BPD patients were working at this level, none of the 52 substance-using patients were so employed [[chi].sup.2] (Yates) = 15.4, df = 1, p = .001].

The impact of substance abuse can be traced to adolescence, especially for the stimulant users. While 36 (90%) of 40 nonsubstance-using BPD patients and 28 (88%) of 32 alcohol-sedative-using patients graduated from high school, only 11 (56%) of 19 stimulant users graduated. This difference was significant ([chi].sup.2] 10.0, df = 2, p = .01).

Of note, prostitution and self-identified promiscuity correlated with substance abuse. While 14 (27%) of 52 substance-using patients described themselves as promiscuous, none of the 40 nonsubstance-using patients endorsed this item. This difference was significant [[chi].sup.2] (Yates) = 11.5, df = 1, p = .001].

Depersonalization-derealization occurred equally among nonsubstance-using and alcohol-sedative-using BPD patients (37 vs 28%), but in only 5% of stimulant users. These differences were significant ([chi].sup.2] = 7.14, df = 2, p = .05). Finally, suicide attempts and gestures occurred equally among substance-using and nonsubstance-using BPD patients (85 vs 90%). This difference was not significant [[chi].sup.2] (Yates) = 0.20, df = 1, p = ns].

DISCUSSION

The most important finding of the study relates to a possible between comorbid substance abuse in BPD and educational, employment, and behavioral difficulties. Few differences emerged when comparing groups regarding the hospital experience itself. The substance-using patients arrived at the index admission with markedly depleted resources and options. Compared with nonsubstance-using patients, they were unemployed or underemployed, poorly educated, and many had turned to prostitution. Prostitution and promiscuity were not found in the absence of comorbid substance abuse. The triad of poor education, underemployment, and the financial burden of drugs may drive the patient toward prostitution. Of course, the opposite may be true. In the setting of prostitution, drug use may evolve as a coping strategy. Of note, prostitution was not exclusively a female activity. The male substance-using BPD patients were just as likely to engage in prostitution as females.

When comparing BPD patients with and without comorbid substance abuse, there were no differences in risk for suicide attempts and gestures. This finding runs counter to literature supporting the view that comorbid alcohol use increases the risk for suicide among a wide spectrum of psychiatric diagnoses. A partial explanation for the lack of a difference is the high rate of suicide attempts and gestures in this population. In fact, suicide attempts and gestures were so common in this population that to identify statistical differences among subgroups is highly improbable.

While depersonalization and derealization are common in both the nonsubstance-using and alcohol-sedative-using BPD patients, the symptoms were rarely found in the stimulant-using group. This finding may reflect an association between anxiety and depersonalization. Patients with high levels of anxiety may gravitate toward alcohol and sedative use to self-medicate anxiety and with the hope of preventing depersonalization-derealization. Stimulant users may have lower resting levels of anxiety when compared to other BPD patients, and stressful situations may not dramatically increase their anxiety. In this setting they appear to seek drugs that alter mood rather than anxiety. Our interpretation of this finding is in accord with investigators who have proposed a self-medication paradigm for substance abuse in BPD and other psychiatric disorders (6, 11-13). Another explanation for the infrequent association of depersonalization and derealization with stimulant use may relate to gender differences. Stimulants were used primarily by men who, as a group, described less depersonalization and derealization than women. However, the difference between episodes of depersonalization and derealization in male and female BPD patients (7 vs 28%) did not reach statistical significance [[chi].sup.2] (Yates) = 1.47, df = 1, p = ns). Finally, for some patients, depersonalization and derealization may be a manifestation of drug withdrawal rather than a symptom of BPD. In our view, therefore, the relationship between BPD, substance abuse, and depersonalization-derealization remains to be clarified.

There are several methodological limitations in the design of this study which should be be noted. The study is retrospective and naturalistic, and depends upon observations made by clinicians and not researchers employing standardized diagnostic assessment instruments. However, we are confident of the diagnosis of BPD and substance-abuse disorders by chart review because our data was reasonably complete, we were conservative in endorsing items, and our reliability was excellent.

In conclusion, our study supports the view that substance abuse in the borderline patient has a substantial and devastating impact on the resources and available options of the patient. At the time of the index admission, substance-using BPD patients were fast becoming marginal members of the community. This view is in agreement with the work of Links et al. who found, in an outcome study of BPD patients, that alcoholism and drug use were associated with poor outcome, especially in the setting of coexisting antisocial personality disorder (14). Finally, our study suggests that clinicians will encounter substance abuse routinely in the hospitalized borderline patient and that confronting it may be the first order of treatment.

ACKNOWLEDGMENT

The authors thank James Igel for his contribution to this article.

REFERENCES

(1.) Baxter, L., Edell, W., Gerner, R., et al., Dexamethasone Suppression Test and Axis I diagnoses of inpatients with DSM-III borderline personality disorder, J. Clin. Psychiatry 45:150-153 (1984). (2.) Akiskal, H. S., Chen, S. E., Davis, G. C., et al., Borderline: An adjective in search of a noun J. Clin. Psychiatry 46:41-48 (1985). (3.) Andrulonis, P. A., Glueck, B. C., Stroebel, C. F., et al., Borderline personality subcategories J. Nerv. Ment. Dis. 170:670-679 (1982). (4.) Pope, H. G., Jonas, J. M., Hudson, J. L., et al., The validity of DSM-III borderline personalit disorder: A phenomenological, family history, treatment response, and long-term follow-up study, Arch. Gen. Psychiatry 40:23-30 (1983). (5.) Frances, A., Clarkin, J. F., Gilmore, M., et al., Reliability of criteria for borderline person disorder: A comparison of DSM-III and the diagnostic interview for borderline patients, Am. J. Psychiatry 45:150-153 (1984). (6.) Dulit, R. A., Fyer, M. R., Haas, G. L., et al., Substance abuse in borderline personality disor Am. J. Psychiatry 147:1002-1006 (1990). (7.) Ogata, S., Silk, K., Goodrich, S., et al., Childhood sexual and physical abuse in adult patient with borderline personality disorder, Am. J. Psychiatry 147:1008-1013 (1990). (8.) Fyer, M., Frances, A., Sullivan, T., et al., Suicide attempts in patients with borderline perso disorder, Am. J. Psychiatry 145:737-739 (1988). (9.) Chu, J., and Dill, D., Dissociation, borderline personality disorder, and childhood trauma, Am. J. Psychiatry 148:812-813 (1991). (10.) Morey, L., Personality disorder in DSM-III and DSM-III-R: Convergence, coverage, and internal consistency, Am. J. Psychiatry 145:573-577 (1988). (11.) Gardner, D. L., and Cowdry, R. W., Alprazolam-induced dyscontrol in borderline personality disorder, Am. J. Psychiatry 142:98-100 (1985). (12.) Khantzian, E. J., The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence, Am. J. Psychiatry 142:1259-1264 (1985). (13.) McLellan, A. T., Woods, G. E., and O'Brien, C. P., Development of psychiatric illness in drug abusers: Possible role of drug preference, New Engl. J. Med. 301:1310-1314 (1979). (14.) Links, P., Mitton, J., and Steiner, M., Predicting outcome for borderline personality disorder Compr. Psychiatry 31:490-498 (1990).

Frank T. Miller,(*) M.D. (*) To whom correspondence should be addressed at Payne Whitney Clinic, 525 East 68th Street, New York, New York 10021.

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