Factors associated with co-occurring borderline personality disorder among inner-city substance users: the roles of childhood maltreatment, negative affect intensity/reactivity, and emotion dysregulation
Introduction
The co-occurrence of borderline personality disorder (BPD) and substance use disorders (SUDs) is a common and clinically relevant phenomenon in need of further empirical investigation [1], [2]. Reported rates of co-occurring BPD among substance users generally range from 10% to 50% [3], [4], [5], [6], [7], [8], [9], with a recent review indicating an average rate of 19% across studies [2]. Moreover, BPD-SUDs comorbidity is associated with greater impairment and a worse prognosis than either disorder alone [1], [4]. For example, although both BPD and SUDs are associated with heightened risk of suicide, BPD-SUDs comorbidity is associated with an even higher risk [1], [5], [10]. Further, the presence of co-occurring BPD among substance users has been found to be associated with higher levels of substance use [10], more severe SUD symptoms [7], higher rates of needle sharing [5], and greater health-related problems, including more injection-related health problems, higher levels of overdose, and poorer psychological health [10]. Finally, recent findings suggest that the presence of BPD among substance users is associated with poorer treatment outcomes, including worse drug use outcomes [11], higher treatment dropout rates, and higher levels of risky, harmful behaviors [10]. As such, research focused on elucidating the factors associated with co-occurring BPD among substance users has great public health significance.
In particular, research suggests the importance of examining the factors associated with BPD among inner-city substance users, a population that may be especially vulnerable to developing BPD [12], [13] due to their heightened risk for many of the hypothesized risk factors for BPD (including BPD-relevant personality traits and childhood abuse) [14], [15], [16]. Indeed, a study of BPD symptoms among a community sample of individuals with alcohol use disorders found that individuals with high levels of BPD features were significantly more likely to live in an urban area (vs a rural area) [17]. Furthermore, findings among a random community sample of 1541 adults indicate a trend for higher rates of BPD among individuals who are nonwhite, from urban areas, and of lower socioeconomic status [18].
Extant models of the pathogenesis of BPD, not specific to BPD-SUDs comorbidity, suggest that BPD results from the interaction of particular environmental stressors and biologically based vulnerabilities [19], [20], [21], [22]. In regard to the former, researchers have highlighted the role of adverse childhood experiences in the development of BPD, in particular childhood maltreatment [20], [21], [22]. Specifically, studies have provided support for the role of sexual abuse [23], [24], [25], [26], physical abuse [27], [28], [29], emotional abuse [12], [23], [29], and emotional and physical neglect [20], [29], [30], [31] in the risk of BPD.
In regard to the biologically based vulnerabilities associated with BPD, many researchers have focused on the role of affective dysfunction, or emotional vulnerability, in BPD [19], [22], [32], [33], [34], with Linehan [20] highlighting the centrality of affect intensity (ie, the tendency to experience emotions strongly), emotional reactivity (ie, high sensitivity to emotional stimuli), and delayed emotional recovery (ie, slow return to baseline levels of emotional arousal following the activation of an emotion). Although limited research has examined this latter form of emotional vulnerability in BPD, research does provide support for a relationship between affect intensity/reactivity and BPD. Specifically, research indicates that individuals with BPD report higher levels of affect intensity/reactivity than do individuals with other personality disorders [35], [36] or bipolar II disorder [35]. However, recent evidence suggests that the relationship between affect intensity/reactivity and BPD may be specific to negative emotions. Specifically, Levine et al [37] found that individuals with BPD (compared with individuals without BPD) reported higher levels of negative affect intensity/reactivity but similar levels of positive affect intensity/reactivity, highlighting the importance of negative affect intensity/reactivity in particular in BPD.
Moving beyond these environmental stressors and biologically based vulnerabilities, Linehan's [20] theoretical work on the development of BPD emphasizes the centrality of emotion dysregulation in this disorder, suggesting that emotion dysregulation mediates the relationship between the combined influences of an invalidating environment (including childhood abuse and neglect) and emotional vulnerability and the later development of BPD. Unlike affect intensity/reactivity, emotion dysregulation (as defined here) does not refer to the nature or quality of one's emotional responses. Instead, emotion dysregulation refers to maladaptive ways of responding to one's emotions (regardless of their intensity or reactivity), including nonaccepting responses, difficulties controlling behaviors in the face of emotional distress, and deficits in the functional use of emotions as information [38]. Emotion dysregulation is therefore distinguished from emotional vulnerability, as affect intensity/reactivity does not preclude adaptive regulation. Importantly, despite growing evidence for a relationship between emotion dysregulation and BPD [37], [39], [40], [41], as well as literature suggesting that both affect intensity/reactivity [42], [43], [44] and childhood maltreatment [45], [46], [47] increase the risk of emotion dysregulation, few studies have directly examined the mediating role of emotion dysregulation in the relationships between childhood maltreatment and negative affect intensity/reactivity (and their interaction) and BPD.
Furthermore, despite empirical support for the role of each of these factors in BPD, the extent to which they are associated with co-occurring BPD among inner-city substance users is unclear. That is, given that substance use in and of itself has been found to be associated with similar risk factors (eg, childhood abuse, see Brems et al [48], Burnam et al [49], and Kilpatrick et al [50]), it is unclear whether the factors associated with BPD in general will also be associated with co-occurring BPD among inner-city substance users. In particular, given literature suggesting that substance use may serve an emotion-regulating function [51], [52], [53], as well as findings of a relationship between emotion dysregulation and substance use [54], [55], it is unclear if emotion dysregulation will predict co-occurring BPD among substance users or, conversely, if heightened levels of emotion dysregulation among the sample as a whole will create a ceiling effect for this variable, limiting its ability to distinguish between groups of substance users (ie, those with and without BPD). Indeed, given that substance users in general have been found to evidence heightened emotion dysregulation [54], [55], findings of higher levels of emotion dysregulation among substance users with BPD (compared to those without BPD) would provide important information regarding the potential centrality of emotion dysregulation to BPD.
Thus, the present study sought to extend extant research by examining the factors associated with co-occurring BPD pathology among inner-city substance users. Specifically, this study examined the role of childhood maltreatment (including sexual, physical, and emotional abuse, as well as physical and emotional neglect), negative affect intensity/reactivity, and emotion dysregulation in 2 BPD-related outcomes (diagnosis and symptom count). We hypothesized that emotion dysregulation would mediate the relationships between childhood maltreatment and negative affect intensity/reactivity (and their interaction) and co-occurring BPD pathology among substance users. Further, post hoc analyses explored whether specific forms of maltreatment are uniquely related to BPD pathology (both diagnostic status and symptom count) among substance users.
Section snippets
Participants
Participants were inpatient residents in a drug and alcohol abuse treatment center in Northeast Washington, DC. Treatment at this center involves a mix of strategies adopted from Alcoholics and Narcotics Anonymous, as well as group sessions focused on relapse prevention and functional analysis. The center requires complete abstinence from drugs and alcohol (including any form of pharmacological treatment, such as methadone), with the exception of caffeine and nicotine; regular drug testing is
Identification of covariates
Preliminary analyses were conducted to explore the impact of demographic factors (including age, gender, and racial background) and relevant clinical characteristics (including the number of drugs on which participants were dependent, past year substance use, ASPD, and number of days in treatment before study participation) on emotion dysregulation, BPD diagnostic status, and BPD symptom count, in order to identify potential covariates for later analyses [85]. Emotion dysregulation, BPD
Discussion
The present study adds to the literature on the pathogenesis of BPD, examining the factors associated with the presence of co-occurring BPD pathology among inner-city substance users (an underserved population at heightened risk of many of the hypothesized risk factors for BPD) [14], [15], [16]. Specifically, this study examined the role of childhood maltreatment (including sexual, physical, and emotional abuse, and physical and emotional neglect), negative affect intensity/reactivity, and
Acknowledgment
The authors thank Walter Askew of the Salvation Army Harbor Lights Residential Treatment Center of Washington, DC, for assistance with participant recruitment.
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