Dear Editor:
Clinicians have long recognized that some individuals with eating disorders suffer from chronic self-harm behavior (SHB) and some from borderline personality disorder (BPD)—but is there any relationship between these two phenomena? According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,1 one of the criteria for BPD is “recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.” The theme of chronic SHB is also supported by various diagnostic measures for BPD including the Diagnostic Interview for Borderlines.2 While the explicit presence of chronic SHB in association with BPD among those with eating disorders remains elusive, some consider SHB and BPD as somewhat synonymous entities. On a precautionary note, Wonderlich and colleagues3 advise that “self-harm behaviors should not be considered the sine qua non of BPD.”
In addition to a possible relationship between chronic SHB and BPD among those with eating disorders, several studies have explored the impact of Axis II psychopathology on eating-disorder treatment outcome.4 While conclusions have been controversial (i.e., from little to significant impact), Wilfrey and colleagues5 and Steiger and Stotland6 found BPD to be a negative predictor of treatment outcome.
We wondered how, among those with eating disorders, the prevalence rate of BPD, the prevalence rates of self-injury and suicide attempts, and the percentage of individuals with negative treatment outcomes, might compare. If similar, this might suggest a possible relationship among these phenomena; if dissimilar, a relationship would seem less likely.
In our previous work, we determined that the prevalence of BPD among eating disorder subjects (diagnostically grouped together, excluding binge eating disorder; N=1840) in empirical studies is 26 percent.7 Likewise, we previously determined that the prevalence of self-injury and suicide attempts among both inpatients and outpatients with eating disorders is 25 percent (221/886 individuals) and 28 percent (266/957 individuals), respectively.8 The final task was to determine the prevalence of poor treatment outcome among eating-disorder subjects. To explore this, we elicited articles through an extensive search of the PubMed and PsycINFO databases, using relevant search terms. These are summarized in Table 1. While we may not have obtained all available articles, note that the total subject numbers in Table 1 are over 9,000 and that the overall percentage of patients with poor treatment outcomes is 24 percent.
Table 1.
Summary of the majority of treatment outcome studies for eating disorders
| First Author | Year | N | Diagnoses | Negative Outcome n (%) | Definition of Negative Outcome |
|---|---|---|---|---|---|
| Fallon9 | 1991 | 46 | BN | 19 (41) | Unrecovered |
| Olmsted10 | 1994 | 48 | BN | 15 (31) | Relapse |
| Eckert11 | 1995 | 76 | AN | 58 (76) | Unrecovered |
| Keel12 | 1997 | 2194 | BN | 658 (30) | Relapse |
| Keel13 | 1998 | 173 | BN | 51 (29) | Unrecovered |
| Ben-Tovim14 | 2001 | 220 | Mixed | AN: 42 (44) BN: 23 (26) EDNOS: 8 (22) |
Continuing eating disorder diagnosis |
| Herpertz-Dahlmann15 | 2001 | 39 | AN | 12 (31) | Not full recovery |
| Nakai16 | 2002 | 222 | Mixed | AN: 41 (30) BN: 22 (26) |
Unrecovered, deceased |
| Sherman17 | 2002 | 246 | Mixed | 27 (11) | Unrecovered |
| Steinhausen18 | 2002 | 5590 | AN | 1118 (20) | Chronically ill |
| Lee19 | 2003 | 83 | AN | 7 (8) | Unrecovered, deceased |
| Steinhausen20 | 2003 | 242 | Mixed | 73 (30) | Unrecovered |
| TOTAL | 9180 | 2174 (24) |
Note
- AN =
anorexia nervosa
- BN =
bulimia nervosa
- EDNOS =
eating disorder not otherwise specificed
These various percentages (i.e., the prevalence of BPD, the prevalence of suicide attempts, the prevalence of self injury, percent of patients with negative treatment outcomes) are within four percent of each other. Is this interesting proximity merely coincidental (i.e., are these phenomena genuinely independent of each other, with approximately one quarter of eating disorder patients suffering from BPD, one quarter demonstrating SHB, and one quarter failing treatment?) or is there a possible relationship among them? If related, could it be that BPD is inherently linked to SHB and that either or both phenomena predispose to poor treatment outcome? While some studies support aspects of these preceding hypothetical relationships, we are not aware of any single study that has simultaneously studied BPD, SHB, and treatment outcome in an eating disordered population. Because of the close percentages noted in our findings, these phenomena warrant further investigation in a single study.
The potential limitations of our data summary in Table 1 include the collective inclusion of various types of eating disorder diagnoses (except binge eating disorder) into one study population, missing studies (e.g., abstracts, conference presentations, articles missed by our search terms), and the varying methodologies used in the reported studies (e.g., a range of definitions of “treatment failure”). However, we believe that the proximity of these percentages is very interesting and warrants further empirical study.
With regards,
Randy A. Sansone, MD
Professor, Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio; Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio
Lori A. Sansone, MD
Contract physician (family medicine), Wright-Patterson Air Force Base in Dayton, Ohio
Contributor Information
Randy A. Sansone, Professor, Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio; Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio.
Lori A. Sansone, Contract physician (family medicine), Wright-Patterson Air Force Base in Dayton, Ohio.
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