by Michael D. Anestis, M.S.
If any of you listened to last week's episode of "Science Friday" on NPR, which featured Richard McFall, Bruce Wampold, and Dianne Chambless discussing the importance of science in clinical psychology, you likely heard a caller towards the end of the show raise a very important point. A significant problem, she said, is that much - although by no means all - of our research on psychopathology and psychotherapy has been conducted on predominantly Western Caucasian samples of at least moderate socioeconomic status. This, of course, raises questions regarding the degree to which what we know about mental illness applies to other cultures and populations.
Without question, there are several wonderful exceptions to this problematic situation and today I would like to discuss a newly published example. In this study, published in the Journal of Personality Disorders by See-wai Leung and Freedom Leung (2009), the authors examined the degree to which the concept of borderline personality disorder (BPD) exists in Chinese adolescents in the same form it is found in the United States and, if so, how common the disorder might be in that population. To justify their efforts to examine these questions, Leung and Leung (2009) provided a thorough background on the current situation. Approximately 1-2% of the general population in Western world meets criteria for BPD (Torgersen, Kringlen, & Cramer, 2001). The DSM-IV-TR indicates that the diagnosis can be applied to adolescents; however, many researchers and clinicians argue that this should not be the case because adolescence is a time of change and many of the symptoms of BPD (e.g., identity disturbance, rapidly shifting emotions) are actually quite normative during this period of development.
The debate about whether or not to apply BPD diagnoses is an interesting one and those against such diagnostic decisions can turn to some fairly compelling data to support their case. Specifically, Bernstein and colleagues (1993) found that less than 30% of the adolescents who initially met criteria for BPD in their sample still met those criteria two years later and not because they were typically receiving effective treatment. Given that personality disorders are theorized to be fairly stable, this presents a bit of a problem. At the same time, other researchers have explained these findings in an interesting way. For example, Meijer, Goedhart, and Treffers (1998) pointed out that, while the diagnosis itself might not be particularly stable across time, certain characteristics of the disorder are. Put simply, some symptoms such as non-suicidal self-injury (NSSI), suicidal behaviors, and dissociation might fluctuate over time, becoming more and less common at different points, whereas other symptoms, such as unstable moods and difficulty controlling anger might be more stable. In fact, in their sample, while only 30% of individuals who demonstrated the former set of symptoms initially did so again at follow-up, 70% of individuals who demonstrated unstable moods and under-controlled anger did so at follow-up. If you remember our discussion of the possibility of a dimensional model of personality disorders in DSM-V, this might make a lot of sense to you, as such models suggest that we all might have varying amounts of particular symptoms at a given moment. So, while some personality characteristics might be rather stable and represent a vulnerability to an outcome (e.g., a diagnosis of BPD), some personality characteristics and behaviors might not be quite so stable and may disappear altogether at times or simply become less prominent (thereby influencing diagnostic status).
Lueng and Lueng (2009) looked at these findings as well as a number of factor analyses of BPD in adolescents and concluded that, while there is room for discussion on particulars of the issue, the concept of BPD in adolescents appears to be valid. How common BPD is in adolescence, on the other hand, is less clear, as studies that have aimed to determine that have been highly flawed.
All of the information we've discussed so far has centered on Western populations. The authors of this study, however, were interested in examining these questions in Chinese adolescents. Currently, BPD is not a part of the mental health diagnostic system of China (Chinese Classification of Mental Disorders - III; Chinese Psychiatry Association, 2001). Psychologists in China argue that the concept of BPD is overly vague and that particular components, such as a fear of abandonment, are not culturally appropriate in that context. These points, however, represent empirical questions, the type of question better answered through systematic studies than through discussions amongst committee members, particularly given the mountains of evidence for the existence of the syndrome in other parts of the world. Importantly, Lueng and Lueng (2009) pointed out, if BPD exists in China with prevalence rates comparable to that of the West, that means that there are 13 to 26 million Chinese suffering from these symptoms without being properly diagnosed and treated. It goes without saying that this would be an unacceptable situation, particularly given that a strong empirically supported treatment - dialectical behavior therapy (DBT) - exists for this diagnosis.
The authors spent a lot of time discussing various models of BPD that, quite frankly, would be difficult to describe on PBB without relying upon a lot of complicated jargon. That being said, if you are interested in reading about the factor structure of BPD in detail, I recommend reading the full article and/or contacting me for more details. Here, I'll focus on some of the more straight forward results. First, however, let's discuss how the study was conducted. At Time 1, 5,224 adolescents between the ages of 12 and 20 filled out a series of questionnaires. One year later, at Time 2, 5,461 adolescents filled out those same questionnaires. 4,110 individuals were assessed at both time points and the vast majority of those who only took part in Time 1 did so because they graduated and were no longer available. Due to strong encouragement by school administrators, nearly 99% of eligible students participated in the study.
Lueng and Lueng (2009) were hoping to conduct structured diagnostic interviews on each participant; however, the schools demanded complete anonymity in the study and such procedures were ruled out. As a result, diagnoses of BPD were determined through two alternative methods. The first was through a cut-off point on a self-report measure of BPD. The second was through a method developed specifically for this study. The authors selected three self-report questions from the questionnaires that represented each symptom and only gave a diagnosis if a participant endorsed all three items for at least five BPD symptoms (an attempt to mirror the DSM requirements). Neither of these approaches is ideal.
The authors' findings were very interesting...and highly supportive of the idea that BPD not only exists in Chinese adolescents, but exists in the same form as found in the West. Again, the details of the factor structure of BPD in Chinese adolescents is a topic that requires a closer reading of the original document, but to summarize those findings, the authors demonstrated that the symptoms that tend to cluster together in the US clustered together in the same way in this Chinese sample. In other words, the grouping of BPD symptoms does not appear to simply reflect a Western bias. Chinese adolescents were just as likely to display a syndrome defined by unstable emotions, impulsive behaviors, disturbances in self-image, and chaotic interpersonal relationships.
The next question, however, is how common these symptoms are in this population. The answer, not surprisingly, depended upon the method used for determining diagnoses. Using the simple cut-off score mentioned above, 7.7% of females and 5.0% of males met criteria for BPD. These numbers clearly represent a greater vulnerability in females and are substantially higher than the rate in the general population in the West (although remember, that Western rate is not specific to adolescents). When the more stringent method mentioned above was used, only 2.2% of females and 1.8% of males met criteria for BPD. Using this approach, sex differences disappeared and the prevalence rates became similar to those found in the West. So, BPD appears to be at least as common in Chinese adolescents as it is in the West.
Before wrapping up their study, Lueng and Lueng (2009) looked at one last question: how stable are BPD features in Chinese adolescents? Using the simplest way of testing this question - looking at the correlation between overall symptoms at Time 1 and Time 2 - the results indicated that BPD was fairly stable (r = .60 for females and .51 for males; p < .001). Looking at diagnoses with the cut-off score, however, the picture was different. Only 36.8% of females and 36.2% of males who met BPD criteria at Time 1 also met those criteria at Time 2. This result looks very similar to those of Bernstein and colleagues (1993) that I mentioned earlier. Much like the Meijer et al (1998) findings I mentioned above told us, however, there is more to that picture. Specifically, certain symptoms - particularly paranoid thoughts and unstable moods - were highly stable, whereas others - particularly impulsive behaviors, fear of abandonment, NSSI, and suicidal behaviors - were more likely to come and go between time points. So, the overall picture is that symptoms in general are fairly stable, but some symptoms are more stable than others, which means that meeting criteria for the diagnosis of BPD at one point is no guarantee that the same will be true a year later.
I was very excited when I found this study. The topic is inherently interesting to me and research like this is incredibly valuable, as it helps us to get a better sense of whether or not what we study in the US applies to the rest of the world. Obviously, this is only one study and it is not without its imperfections, but it was nonetheless incredibly informative. If BPD truly is as common in China as it is in the West, that means there are tens of millions of people in that country who are not receiving adequate care for a disorder marked by a highly elevated suicide rate and who likely have little understanding about why such symptoms cluster together and impact their lives as they do. Given that BPD is not a part of the Chinese diagnostic system, it seems highly unlikely that a substantial proportion of Chinese therapists are trained in DBT, which means that even if the diagnostic system were updated to reflect these data, help would not be readily available. Studies like this shine a light on areas of weakness and hopefully can serve as the first step in a chain reaction of changes that ultimately result in the greater proliferation of accurate information, the development of more efficient and effective diagnostic approaches, and the implementation of a system of mental health care that adequately addresses the needs of consumers.
If you would like to learn more about borderline personality disorder and dialectical behavior therapy, we recommend the following items, each of which can be found in our online store for scientifically-based psychological resources:
- Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan
- Cognitive-Behavioral Treatment of Borderline Personality Disorder
by Marsha Linehan
- Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings by Linda Dimeff and Kelly Koerner
- Dialectical Behavior Therapy with Suicidal Adolescents by Alec Miller, Jill Rathus, and Marsha Linehan