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. Author manuscript; available in PMC: 2015 Dec 23.
Published in final edited form as: Personal Disord. 2010 Oct;1(4):250–257. doi: 10.1037/a0019313

Refining Behavioral Dysregulation in Borderline Personality Disorder Using a Sample of Women with Anorexia Nervosa

Edward A Selby 1, Cynthia M Bulik 2, Laura Thornton 2, Harry A Brandt 3, Steve Crawford 3, Manfred M Fichter 4, Katherine A Halmi 5, Georg E Jacoby 6, Craig L Johnson 7, Ian Jones 8, Allan S Kaplan 9, James E Mitchell 10, Detlev O Nutzinger 11, Michael Strober 12, Janet Treasure 13, D Blake Woodside 9, Walter H Kaye 14, Thomas E Joiner Jr 1,*
PMCID: PMC4688899  NIHMSID: NIHMS743896  PMID: 22448667

Abstract

One of the primary facets of borderline personality disorder (BPD) is behavioral dysregulation, a wide array of behaviors that are difficult to control and harmful to the individual. The purpose of this study was to explore the association between BPD and a variety of dysregulated behaviors, some of which have received little empirical attention. Using a large sample of individuals diagnosed with anorexia nervosa, 41 individuals diagnosed with BPD were compared to the rest of the sample on the presence of dysregulated behaviors using logistic regression analyses. Anorexia nervosa subtypes, age, and other Cluster B personality disorders were used as covariates. Results support an association between BPD and alcohol misuse, hitting someone/breaking things, provoking fights/ arguments, self-injury, overdosing, street drug use, binge-eating, impulsive spending, shoplifting/stealing and risky sexual behaviors. Differences between dichotomous and continuous measures of BPD yielded somewhat different results.

Keywords: borderline personality disorder, behavioral dysregulation, substance abuse, anorexia nervosa

Dysregulated behaviors are, by definition, difficult to control, and often result in functional impairment for the affected individual (Selby & Joiner, in press). Individuals with borderline personality disorder (BPD) are generally thought to engage in various dysregulated behaviors ranging from non-suicidal self-injury (NSSI) to physical fights, and the diagnostic criteria for BPD reflect this (APA, 1994). Yet many of the behaviors that individuals with BPD are generally thought to engage in have insufficient empirical support linking them to an actual BPD diagnosis. One such example is impulsive spending, which can contribute to one criterion for a diagnosis of BPD (APA, 1994), yet, to our knowledge, there are no empirical studies actually linking BPD to impulsive spending. The purpose of this study was to explore the relation between BPD and a variety of potentially dysregulated behaviors, with the goal of providing empirical support for using these behaviors as criteria in BPD diagnosis.

Although there are some dysregulated behaviors that have an unclear relation to BPD, there are a few behaviors that have a well established association: NSSI (Brown, Comtois, & Linehan, 2002; Selby et al., 2009), binge-eating (Marino & Zanarini, 2001; Sansone, Wiederman, & Sanson, 2000; Selby et al., 2009), substance abuse (Bornovalova et al., 2005), and suicide attempts (Duberstein & Conwell, 1997). Reductions in some of these behaviors are often considered as signs of successful treatment (Linehan, 1993). Yet, as has previously been mentioned, some behaviors have minimal or no empirical evidence supporting a relation to BPD. As with impulsive spending, there are, to our knowledge, no studies that have found a relation between reckless driving and BPD. Only one study found evidence for a relation between shoplifting/stealing and BPD (Grant, 2004).

Some of the behaviors anecdotally linked with BPD appear to have mixed supporting evidence. Take, for example, the DSM-IV-TR indication that individuals with BPD engage in risky or sexually promiscuous behaviors (APA, 1994). Few studies have actually examined this association, and the results have been equivocal (Daley, Burge, & Hammen, 2000; Hull & Clarkin, 1993; Lavan & Johnson, 2002; Zanarini et al., 2003). Physical fights and arguments are also behaviors that are considered a part of BPD, yet the empirical evidence on the link between aggressive behaviors and BPD is also mixed, with some studies finding support for a link between BPD and physical aggression (Critchfield, Levy, Clarkin, & Kernberg, 2008; Raine, 1993) and others failing to find this relation (Fossati et al., 2004; Gardner et al., 1991). A general conclusion can be drawn from this discussion of dysregulated behaviors and BPD: individuals with BPD engage in a number of dysregulated behaviors that are well established (NSSI, binge-eating, etc.), but more empirical evidence is needed to support the relation of other, less well established dysregulated behaviors in relation to BPD.

The current study aimed to address some of these lacunae in the empirical data linking some dysregulated behaviors to BPD with a large sample of individuals with anorexia nervosa (AN). BPD has often been studied as a co-occurring disorder with bulimia nervosa (Chen et al., 2008; Godt, 2008), but to our knowledge, few previous studies have explored BPD in individuals with AN. Furthermore, BPD is the among the most common personality disorders found in AN regardless of AN subtype (Bornstein, 2001; Cassin & von Ranson, 2005; Sansone, Levitt, Sansone, 2005). Because of these high co-occurrence rates, exploring BPD in those with AN is an important, yet understudied, area.

Although individuals with AN, particularly those with restricting subtype (ANR), tend to demonstrate more compulsive behavior (e.g., hoarding food, excessive exercising), those with purging (ANP) and binging-purging (ANBP) subtypes tend to display elevated levels of behavioral dysregulation beyond the scope of dysregulated eating behaviors (Tozzi et al., 2006; Wonderlich, Connolly, & Stice, 2004). In fact, those with ANBP often engage in NSSI, drug use, and shoplifting, and they frequently engage in suicide attempts (Bulik et al., 2008), behaviors that are often associated with BPD. Given that those with ANBP have higher rates of co-occurring BPD than those with ANR, the question arises as to whether those with ANBP endorse these behaviors as a function of BPD, or if ANBP solitary from BPD can instigate behavioral dysregulation. It is also possible that those with co-occurring AN diagnoses and BPD may experience synergistic effects of the disorders, where both diagnoses increase problems with behavioral dysregulation more so than either disorder alone. Either way, comparing a group of individuals with both AN and BPD to a group of those with AN and no BPD diagnosis makes for an interesting comparison, and further illuminates a research area that has often been overlooked.

This study evaluated a variety of dysregulated behaviors in a large sample of individuals with AN, many also diagnosed with BPD. Although using a more general sample of individuals with BPD may be ideal for refining behavioral dysregulation in BPD, the current sample still provides useful information and it also allows for more information about co-occurring BPD and AN to be generated. We hypothesized that BPD diagnosis would significantly predict endorsement of the following behaviors, even after controlling for co-occurring psychopathology: NSSI, binge-eating, shoplifting/stealing, alcohol misuse, hitting someone/breaking things, provoking fights or arguments, overdosing, street drug use, impulsive spending, and risky sexual behaviors. These same behaviors were also predicted using a continuous measure of BPD symptoms to determine if differences in the two measures arose.

Methods

Participants

Participants consisted of 718 female participants of primarily European ancestry (97.4%) enrolled in a NIH funded Genetics of Anorexia Nervosa (GAN) Collaborative Study. As a part of this study, all participants were assessed for a diagnosis of BPD, with 41 participants meeting diagnostic criteria for BPD. This study took place at multiple sites in various research and clinical settings across North America and Europe. The full methods for this investigation can be found in Kaye et al. (2008). To be included in this study all participants had to be over age 16 and the majority had a lifetime diagnosis of anorexia nervosa (AN) according to DSM-IV criteria, minus criterion D (amenorrhea), at least 3 years before entry into the study and by age 45. In order to participate in the study probands were required to have at least one first through third degree relative with AN who was willing to participate in the study. Exclusion criteria for potential probands included: a history of severe CNS trauma, psychotic disorders, developmental disability, or any other medical, neurological, or substance use disorder that could confound a diagnosis of AN or interfere with the proband’s responding to assessments. Individuals with a lifetime BMI exceeding 30 kg/m2, and individuals who did not speak either English or German were excluded from the study. The age of participants ranged from 16 to 81, with an average age of 30.6 (SD=12.1). Males were excluded from the current study because dysregulated behaviors can vary between genders, and there were not enough males in the current sample to make meaningful comparisons. There were also no males with BPD in the present sample.1

Borderline Personality Disorder (BPD) and Other Axis II Psychopathology

Although the primary focus of the GAN study was on eating disorders, specifically AN, Cluster B and C personality disorders were also assessed. The primary focus of the current study was on BPD, although other Cluster B personality disorders were used as covariates in the analyses. All Axis II personality disorders were assessed using the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II; First et al., 1997). The impulsivity criterion for BPD was modified such that individuals who reported binge-eating were required to endorse three (instead of two) dysregulated behaviors because this was an eating disordered sample. In this sample 41 (5.7%) individuals met diagnostic criteria for BPD, 10 (1.8%) met criteria for narcissistic personality disorder (NPD), 3 (0.4%) met criteria for antisocial personality disorder (ASPD), and no individuals met criteria for histrionic personality disorder (HPD). The inter-rater reliability of participant Axis I and II diagnoses in the GAN study ranged from .80 to 1.0, as calculated using an algorithm which scored the diagnoses for a random sample of participants and as checked against the primary reviewer (Kaye et al., 2008). Because of the inter-rater reliability algorithm used, specific inter-rater reliability for BPD was not available in the current sample. Inter-rater reliabilities for AN diagnoses were all over .95.

Because of recent movement in the field of personality disorders to examine dimensional versions of the personality disorders (Widiger & Trull, 2007), and in doing so to account for subthreshold symptoms of personality disorders, we also generated a continuous measure of BPD. Each symptom of BPD on the SCID-II is rated as follows: (1) for absence of the symptom, (2) for subthreshold level of a symptom, and (3) for threshold presence of symptom. The continuous measure of BPD was created by summing the threshold ratings of all BPD symptoms except criteria four and five, which involve behavioral dysregulation. This measure demonstrated adequate internal consistency (α = .79) and in the current sample the continuous BPD measure had a mean of 9.40 (SD = 3.06), and was normally distributed.

Assessment of Eating Disorder Pathology

To assess for a diagnosis of AN the Extended Screening Instrument was used (see Kaye et al., 2008). This is an expanded, modified version of Module H of the Structured Clinical Interview for Axis I Disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 1997). Participants were primarily diagnosed with a lifetime history of AN, specified with subtypes of ANR, ANP, or ANBP. Some individuals had a lifetime history of both AN and BN at different points of their illness, and these participants were classified as ANBN. Among those diagnosed with BPD, 24% were diagnosed with ANR, 26% were diagnosed with ANP, 32% were diagnosed with ANBP, and 18% were diagnosed with ANBN. Individuals with BPD were diagnosed with significantly higher frequencies of ANBP than ANBN (χ2(1) = 12.70), and there were no significant differences between rates of the other AN subtypes in the BPD group.

Dysregulated Behaviors

The Eatatelife Phenotype (EATATE), Version 2.1, January 19, 2001 (Project EHE, 2001), is a semi-structured interview that was administered in order to gather information on the following behaviors: excessive alcohol consumption (defined as drinking more than was sensible or more than 38 drinks each week), shoplifting or stealing, hitting someone or breaking things, provoking fights or arguments, NSSI (including cutting, hitting, burning, or biting oneself), overdosing, using street drugs (defined as LSD, heroine, amphetamines, or other illicit substances), excessive/ impulsive spending, and involvement in sexual activities that could be defined as reckless or disinhibited. Gambling and setting fires were also assessed as dysregulated behaviors on the EATATE, but interestingly no participants with BPD reported engaging in either of these behaviors, and less than one percent of the other participants reported engaging in these behaviors. Because of the power issues that arise with the low rates of these behaviors in this sample, they were not included in any of the subsequent analyses.

The behaviors on the EATATE interview were coded as (1) if the participant a) reported engaging in the behavior, and b) reported at least ONE of the following qualities of the behavior: indication that the participant felt that this behavior was out of control, the participant indicated concerns about the behavior, the participant regretted engaging in the behavior, or the participant felt that the behavior caused suffering or distress. Interviewers were instructed to ask follow-up questions for each behavior endorsed to determine if the second criterion (b) for the behaviors was met. If the participant did not endorse that behavior or did not endorse at least one aspect of criterion (b), then the behavior was coded (0) for that participant. The EATATE interview was conducted in addition to the SCID-II.

Data Analytic Strategy

We used multiple logistic regression analyses to predict each behavior on the EATATE using BPD diagnosis as the predictor variable. Although using BPD diagnoses assessed by the SCID-II to predict dysregulated behaviors may seem circular, as some of these behaviors can be used to satisfy diagnostic criteria for BPD using the SCID-II, the purpose of these analyses was to determine if those individuals diagnosed with BPD actually endorsed these behaviors at higher rates than the comparison group. Accordingly, some behaviors may satisfy criteria for a BPD diagnosis (i.e. risky sexual behavior or substance abuse), but that does not necessarily mean that individuals diagnosed with BPD endorsed these behavior more frequently than the AN comparison sample. This method also has the strength of identifying some dysregulated behaviors that may not have been accounted for by the SCID-II, as only two impulsive behaviors (or three in the case of binge eating in this sample) are required for the impulsivity criterion, yet more (or less) may be endorsed.

A continuous measure of BPD symptoms was also used to predict each behavior. This continuous measure had the added benefit of capturing subthreshold symptoms, and the two main behavioral criteria for BPD (criteria four and five) were not included in the measure, removing potential overlap problems with the dysregulated behaviors. The following diagnoses were also used as covariates: AN subtype, ASPD, and NPD. AN subtypes were used as covariates because all individuals in this sample were required to have an AN diagnosis in order to participate. It was important to control for AN subtypes, as some may influence the associations between BPD and certain dysregulated behaviors, especially because individuals with ANP and ANBP have also been found to engage in dysregulated behaviors (Bulik et al., 2008). Binge-eating was the only behavior analyzed without AN subtype included as a covariate, as doing so would over-correct the analysis because binge-eating is a defining characteristic of AN subtype. The other Cluster B personality disorders (except HPD, as no one in the sample met criteria for this disorder) were also used as covariates because these other disorders also involve behavioral dysregulation to some extent (APA, 1994). Participant age was also used as a covariate because of the wide age range in the sample and the potential relevance of age to some behaviors, such as shoplifting/stealing. To correct for multiple comparisons, we used a cutoff based on Tukey’s HSD such that a value of Wald > 3.84 was required for significance at α = .05.

Results

Because these data were intended to study the genetics of AN, data consisted of all participants being related to one or more other participants in the study. This resulted in a potential problem with non-independence of observations. In order to ensure that this issue of non-independence was not influencing the results of this study, all analyses were run a second time using a modified dataset that included only one, randomly-selected member from each family. This ensured that all participants in this second dataset were independent from each other. The results remained essentially the same, with no changes in significant findings, indicating that the pattern of findings is unlikely to be influenced by non-independence of observations.

BPD and Dysregulated Behaviors

The percentages of participants in the BPD and AN comparison groups who reported engaging in each of the dysregulated behaviors are presented in Table 1. Overall, the BPD group had much higher percentages of engaging in these behaviors than the overall sample, with the exception of shoplifting/ stealing, for which there was not a significant group difference. These initial chi-square analyses indicated that there was an overall pattern of more dysregulated behavior in the BPD group as compared to the no BPD group, yet these group differences may have been confounded by co-occurring disorders.

Table 1. Percent of Each Group Endorsing Dysregulated Behaviors.

BPD (N=41)
 No BPD (N=677)
Patient Experience n (%) n (%) χ2 (1)
Binge-Eating 19 (46) 190 (28) 7.56*
Alcohol Misuse 27 (66) 142 (21) 47.33*
Shoplifting/ Stealing 7 (17) 66 (10) 2.71
Hitting/ Breaking Things 9 (22) 49 (7) 12.42*
Provoking Fights/ Arguments 11 (27) 63 (9) 20.06*
Non-Suicidal Self-Injury (NSSI) 23 (56) 150 (22) 27.11*
Overdosing 11 (27) 63 (9) 14.20*
Street Drug Use 18 (44) 71 (10) 43.00*
Impulsive Spending 12 (29) 73 (11) 14.02*
Risky Sexual Behaviors 6 (15) 45 (7) 4.24*
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Note:

*

= significant group difference at p<.05

The results of the logistic regression analyses are displayed in Table 2. First, the results of the analyses using BPD diagnosis as a predictor indicated that most, but not all, of the dysregulated behaviors examined were significantly predicted by a BPD diagnosis. BPD significantly predicted the presence of alcohol misuse (Wald = 29.09, p<.001, OR = 7.10), street drug use (Wald = 22.46, p<.001, OR = 5.60), NSSI (Wald = 18.07, p<.001, OR = 4.56), hitting someone or breaking things (Wald = 10.13, p<.001, OR = 4.01), provoking fights or getting into arguments (Wald = 11.13, p<.001, OR = 3.72), overdosing (Wald = 9.47, p<.001, OR = 3.43), impulsive spending (Wald = 6.56, p<.05, OR = 2.78), and binge-eating (Wald = 6.19, p<.05, OR = 2.33). Interestingly, BPD diagnosis did not significantly predict shoplifting/stealing or risky sexual behaviors.

Table 2.

Series of Logistic Regressions using BPD Diagnosis or Continuous BPD Symptoms to Predict Dysregulated Behaviors

BPD Diagnosis Continuous BPD Symptoms
Behavior B S.E. Wald (df=1) Odds Ratio B S.E. Wald (df=1) Odds Ratio
Binge-Eating .845 .34 6.19* 2.33 .098 .027 13.28* 1.10
Alcohol Misuse 1.96 .36 29.09* 7.10 .168 .029 32.99* 1.18
Shoplifting/ Stealing .48 .47 1.04 ------ .088 .038 5.30* 1.09
Hitting/ Breaking Things 1.39 .44 10.13* 4.01 .208 .039 28.27* 1.23
Provoking Fights/ Arguments 1.31 .39 11.13* 3.72 .234 .037 40.63* 1.26
Non-Suicidal Self-Injury (NSSI) 1.52 .36 18.07* 4.56 .197 .030 42.77* 1.22
Overdosing 1.23 .40 9.47* 3.43 .147 .036 16.36* 1.16
Street Drug Use 1.72 .36 22.46* 5.60 .149 .035 18.10* 1.16
Impulsive Spending 1.02 .40 6.56* 2.78 .142 .041 11.79* 1.15
Risky Sexual Behaviors .58 .52 1.28 ------ .141 .041 11.85* 1.51
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Note:

*

= significant at Tukey HSD corrected p<.05, Results displayed for BPD as the predictor variable. All analyses used the following diagnoses as covariates: Age, ED diagnoses, ASPD, and NPD.

The logistic regression analyses using the continuous measure of BPD symptoms are also displayed in Table 2. The continuous measure of BPD was a significant predictor for all dysregulated behaviors: risky sexual behaviors (Wald = 11.85, p<.01, OR = 1.51), provoking fights/arguments (Wald = 40.63, p<.001, OR = 1.26), hitting/breaking things (Wald = 28.27, p<.001, OR = 1.23), NSSI (Wald = 42.77, p<.001, OR = 1.22), alcohol misuse (Wald = 32.99, p<.001, OR = 1.18), street drug use (Wald = 18.10, p<.001, OR = 1.16), overdosing (Wald = 16.36, p<.001, OR = 1.16), impulsive spending (Wald = 11.79, p<.001, OR = 1.15), binge-eating (Wald = 13.28, p<.001, OR = 1.10), and shoplifting/stealing (Wald = 5.30, p<.001, OR = 1.09). Although the odds-ratios of the continuous measure were smaller than for BPD diagnosis, this is because odds-ratios reflect an increase in the odds of a behavior for one unit of the scale. It is also important to note the inclusion of important covariates – sex, AN subtype, NPD and ASPD – in all of these analyses, suggesting a unique relation between BPD and these behaviors.

Discussion

The results of this study indicated that there was a relation between BPD and alcohol misuse, hitting someone/ breaking things, provoking fights/ arguments, NSSI, overdosing, street drug use, binge-eating, impulsive spending, shoplifting/stealing, and risky sexual behaviors. Novel evidence was found to support impulsive spending, provoking fights/arguments, hitting someone/breaking things, shoplifting/stealing, and risky sexual behaviors as part of a BPD diagnosis. This study also provides information about an understudied yet common diagnostic co-occurrence pattern: AN and BPD. The results indicate that those with both AN and BPD may experience behavioral dysregulation beyond the different AN subtypes alone.

One important finding of this study was that dichotomous BPD diagnosis did not significantly predict shoplifting or risky sexual behaviors, yet a continuous measure of BPD did. These findings suggest that these behaviors may lie on the spectrum of BPD symptoms, yet they may not be as strongly associated with more severe levels of BPD. Future studies should continue to explore the relative weight that BPD diagnosis may have on certain dysregulated behaviors. Some behaviors, such as NSSI, may be better indicators of severe BPD than other behaviors, such as shoplifting. These differences in assessment also highlight the importance of the current debate over the dimensional versus categorical nature of personality disorders.

The co-occurring diagnostic nature of this sample is also an important limitation to consider with these findings, however, because the sample may not be representative of BPD individuals as a whole. The same pattern of results may not be found in BPD individuals without co-occurring eating disorders. Furthermore, there may also be synergistic effects of co-occurring BPD and AN, which may result in elevated levels of behavioral dysregulation. Yet, results were found linking BPD to various dysregulated behaviors when controlling for the various AN subtypes, providing some additional support for the validity of the findings to BPD. Future studies should use case control methodology to compare individuals with both AN and BPD to matched groups of individuals with BPD and other controls to further explore potential differences. Future studies should also attempt to tease apart the synergistic effects that these two disorders may have on dysregulated behaviors when combined.

Another limitation to this study is that the sample is almost entirely of European ancestry. Because of this limitation, the results may not generalize to members of other racial and ethnic groups. One final limitation of the study is that the way behaviors were coded with the EATATE required that each behavior endorsed had to be viewed as distressing, out of control, or a cause for regret by the patient. This may have resulted in underreporting of dysregulated behaviors, as some patients may have endorsed the behavior but not felt that it was distressing. Yet relations between BPD and dysregulated behaviors were still found. This assessment of behavioral dysregulation has the advantage of identifying more severe behavioral dysregulation, as opposed to trying a behavior once, as in the case of alcohol misuse.

Conclusion

The results of this study provide additional evidence for the role of some behaviors in BPD that have previously been established, and it also serves to provide novel evidence supporting the role of shoplifting/stealing, impulsive spending, risky sexual behaviors, and aggressive behaviors in BPD. Differences were found in predicting dysregulated behaviors using dichotomous BPD diagnoses and a continuous measure of BPD, highlighting the importance of refining assessment procedures for BPD. Future studies should attempt to replicate these results in a general sample of individuals with BPD, and potentially extend the findings to other dysregulated behaviors that have yet to be explored, such as reckless driving.

Acknowledgements

This study was funded, in part, by National Institute of Mental Health grant F31MH081396 to Edward A. Selby and Thomas E. Joiner, as well as the following National Institutes of Health Grants (MH066122, MH066117, MH066145, MH066296, MH066147, MH066289, MH066193, MH066287, MH066288, MH066146). Genotyping services were provided by the Center for Inherited Disease Research (CIDR). CIDR is fully funded through a federal contract from the National Institutes of Health to The Johns Hopkins University, Contract Number HHSN268200782096C. The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health. The authors thank the study managers and clinical interviewers of the Genetics of Anorexia Nervosa Collaboration for their efforts in participant screening and clinical assessments. The authors are indebted to Wade H. Berrettini, as well as the participating families for their contribution of time and effort in support of this study.

Footnotes

1

The analyses were also conducted with both sexes included in order to explore whether the inclusion of male participants modified the results, and all analyses were essentially the same, suggesting that the exclusion of males from the analyses had little influence on the results presented.

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