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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres
Prevalence of borderline personality disorder and its risk factors in female MARK
prison inmates in China
Xiao-Min Zhua,b, Jian-Song Zhoua, Chen Chena, Wang-Lian Penga, Wen Lia, Gabor S. Ungvaric,d,
Chee H. Nge, Xiao-Ping Wanga, , Yu-Tao Xiangf,
a
Mental Health Institute of the Second Xiangya Hospital & Hunan Province Technology Institute of Psychiatry & Key Laboratory of Psychiatry and Mental
Health of Hunan Province, Central South University, Changsha, China
b
Suzhou Psychiatric Hospital, The Aliated Guangji Hospital of Soochow University, Suzhou, China
c
University of Notre Dame Australia / Marian Centre, Perth, Australia
d
School of Psychiatry & Clinical Neurosciences, University of Western Australia, Perth, Australia
e
Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
f
Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Macao SAR, China
A R T I C L E I N F O A BS T RAC T
Keywords: High prevalence of borderline personality disorder (BPD) has been found in Western prisons but no such data
Borderline personality disorder exists in China. The objective of this study was to determine the lifetime prevalence of BPD in Chinese female
Female inmates prison inmates and its associated risk factors. This cross-sectional study was conducted in Hunan Provincial
Risk factors Female Prison. Data on consenting inmates socio-demographic and clinical characteristics were collected and
the diagnosis of lifetime BPD was established using the Structural Clinical Interview for DSM-IV. The
prevalence of BPD was 10.6% in the cohort of 2709 participating inmates. Multiple logistic regression analysis
revealed that younger age, unmarried marital status, higher education level, fewer major medical conditions,
more frequent personal and family members drug use, more frequent comorbid psychiatric disorders and
family history of psychiatric disorders were positively and independently associated with BPD. BPD is common
in Chinese female prison inmates. Considering its adverse social consequences and impact on physical and
mental well-being, serious attempts should be made to diagnose BPD early and improve access to treatment in
women prisons.
1. Introduction (Paris, 2008; Solo et al., 2016), which would often lead to
interpersonal conicts and illegal behavior (Sansone et al., 2012;
Female delinquency has grown in recent years in the world Koenig et al., 2016; Kredlow et al., 2017). As a result, individuals
including China contributing to an increase in the number of with BPD are at higher risk to face imprisonment.
female prison inmates (Chesney-Lind and Pasko, 2013). A sys- Many studies on prevalence of BPD have been conducted in the
tematic review comprising ve studies found that the pooled community (Zanarini et al., 2011; Quirk et al., 2016), clinical settings
prevalence of borderline personality disorder (BPD) in inmates (Kealy et al., 2016; Kjaer et al., 2016) and prisons (Wetterborg et al.,
(25%; range: 2229%) (Fazel and Danesh, 2002) is signicantly 2015) in Western countries. However, there have been very few studies
higher than in community samples (2.75.9%) (Grant et al., 2008; on the prevalence of BPD in China (Wang et al., 2007). One possible
Trull et al., 2010). BPD is a complex psychiatric disorder char- reason is that there is the lack of a separate category for BPD in the
acterized by pervasive pattern of instability in interpersonal Chinese Classication of Mental Disorders (CCMD-3) (Chen, 2002).
relationship, self-image and emotion regulation with obvious im- Given the high prevalence of BPD in inmates in Western countries
pulse control problem (American Psychiatric Association, 2013). and the absence of such studies in China, we set out to conduct the rst
Individuals with BPD usually have serious episodic emotion out- study on the lifetime prevalence of BPD in Chinese female inmates and
bursts and destructive behavior in adolescence and early adulthood the associated risk factors.
Correspondence to: Mental Health Institute, The Second Xiangya Hospital, Central South University; Changsha, Hunan, China.
Correspondence to: Faculty of Health Sciences, University of Macau, Avenida da Universidade, 3/F, Building E12, Taipa, Macau SAR, China.
E-mail addresses: xiaop6@126.com (X.-P. Wang), xyutly@gmail.com (Y.-T. Xiang).
http://dx.doi.org/10.1016/j.psychres.2017.01.065
Received 21 October 2016; Received in revised form 22 January 2017; Accepted 22 January 2017
Available online 23 January 2017
0165-1781/ 2017 Elsevier B.V. All rights reserved.
X.-M. Zhu et al. Psychiatry Research 250 (2017) 200203
201
X.-M. Zhu et al. Psychiatry Research 250 (2017) 200203
Table 1
Socio-demographic and clinical data of the study sample.
N % N % N % X2 df p
1USD=6 yuan; BPD=borderline personality disorder; MINI=Chinese version of International Neuropsychiatric Interview; NBPD=Non-borderline personality disorder.
a
Being unemployed prior to their incarceration.
b
Past crimes prior to their incarceration.
inter-personal relationship in BPD is common (Gunderson, 2007), We found that family members of BPD groups had higher rates of
which could explain the high rates of unmarried status in this study. drug use and psychiatric disorders than in the NBPD group. A possible
Unexpectedly, we found a positive association between higher educa- explanation is that family members of individuals with BPD have great
tion and BPD. Considering the average educational level is much lower familial aggregation of impulse spectrum disorders and BPD itself
in this sample than in China nationwide (illiteracy rate: 36.9% vs. (White et al., 2003), which increases the risk of drug use. In this study,
7.3%) (National Bureau of statistics of China, 2013), this nding needs psychiatric disorders in family members of BPD groups were not
to be replicated in future studies. The unemployment rate is 10 times established by diagnostic instruments; therefore we cannot conrm
higher in the current sample compared to the general population in such observation. One study found that family members of BPD
Hunan province, China (43% vs 4.2%) (National Bureau of statistics of individuals had increased prevalence of major depression, anxiety
China, 2014), which may be related to impaired social functions in BPD disorder and suicide (Bandelow et al., 2005), but in another study
(Rendu et al., 2002; Skodol et al., 2002). there was no association between prevalence of schizophrenia and
major depression and family history of BDP (White et al., 2003).
Table 2 As expected, we found that female inmates with BPD had more
Demographic and clinical correlates independently associated with BPD by multiple lifetime comorbid psychiatric disorders established by the MINI. The
logistic regression analysis with the NBPD group as the reference. prevalence (88.9%) in this study is slightly higher than the gure
(82.7%) in community-dwelling BPD sample that only focused on
P value Odds ratio 95% C.I.
mood disorders (Tomko et al., 2014), but lower than that (100.0%) in
Unmarried 0.01 1.4 1.12.0 prisoners sample in the USA (Black et al., 2007). Of the comorbid
Being unemployeda 0.37 1.1 0.81.5 psychiatric disorders in the BPD group, substance dependence was the
Educational level most common (57.6%), which is similar to a previous study (57.4%)
Illiteracy/primary school 1.0
(Trull et al., 2000). The second most common comorbidity was major
Junior middle school 0.88 0.9 0.71.3
Senior middle school and above 0.03 1.4 1.02.1 depression (46.2%), which is much lower than the rate in Swedish male
Drug use in family members 0.02 1.6 1.12.4 oenders (82%) (Wetterborg et al., 2015). The frequency of comorbid
Family history of psychiatric disorders 0.001 2.1 1.33.4 psychotic disorder was only 5.9% in this study since inmates with
Criminal historyb 0.87 1.1 0.71.6
psychotic disorders were rarely admitted to this prison. Furthermore,
Major medical conditions < 0.001 0.5 0.40.7
Personal drug use < 0.001 3.2 2.34.3
comorbid psychiatric disorders may be associated with worse cognitive
Lifetime comorbid psychiatric < 0.001 2.2 1.53.4 impairment and outcomes in BPD (Unoka and Richman, 2016). In a
disorders by MINI UK survey the life expectancy at birth in those with personality
Age < 0.001 0.95 0.940.97 disorder was shorter than in the general population (by 18.7 years
shorter in men and 17.7 years shorter in women (Fok et al., 2012). This
Total model: p < 0.001, R square: 0.205, MINI=Chinese version of International
Neuropsychiatric Interview.
may be related to female inmates with BPD having higher rate of major
a
Being unemployed prior to their incarceration. medical conditions. Unexpectedly, there was a negative relationship
b
Past crimes prior to their incarceration. between major medical conditions and BPD in this study, for which we
202
X.-M. Zhu et al. Psychiatry Research 250 (2017) 200203
have no explanation. This nding needs to be replicated in future Kealy, D., Sierra-Hernandez, C.A., Ogrodniczuk, J.S., 2016. Childhood emotional support
and borderline personality features in a sample of Canadian psychiatric outpatients.
studies. Int J. Soc. Psychiatry.
The results of this study should be interpreted with caution due to Kjaer, J.N., Biskin, R., Vestergaard, C., Gustafsson, L.N., Munk-Jorgensen, P., 2016. The
several methodological limitations. First, only inmates in Hunan clinical trajectory of patients with borderline personality disorder. Pers. Ment.
Health.
provincial Female Prison were included, therefore the ndings could Koenig, J., Rinnewitz, L., Parzer, P., Resch, F., Thayer, J.F., Kaess, M., 2016. Resting
not be generalized to male inmates and to other parts of China. Second, cardiac function in adolescent non-suicidal self-injury: the impact of borderline
due to the cross-sectional design of the study, the causality between personality disorder symptoms and psychosocial functioning. Psychiatry Res. 248,
117120.
BPD and other variables could not be identied. Third, some variables, Kredlow, M.A., Szuhany, K.L., Lo, S., Xie, H., Gottlieb, J.D., Rosenberg, S.D., Mueser,
such as major medical conditions and psychiatric disorders in family K.T., 2017. Cognitive behavioral therapy for posttraumatic stress disorder in
members, were self-reported, therefore recall bias could not be individuals with severe mental illness and borderline personality disorder. Psychiatry
Res. 249, 8693.
excluded. Finally, further information related to BPD, such as severity
Lenzenweger, M.F., Lane, M.C., Loranger, A.W., Kessler, R.C., 2007. DSM-IV personality
of compulsivity, were not collected. disorders in the National Comorbidity Survey Replication. Biol. Psychiatry 62,
In conclusion, this prevalence study found that BPD is common in 553564.
Chinese female prison inmates. Considering the adverse social con- Leshem, R., Glicksohn, J., 2007. The construct of impulsivity revisited. Personal. Individ.
Dier. 43, 681691.
sequences of BPD, and its impact on physical and mental health, Maei, C., Fossati, A., Agostoni, I., Barraco, A., Bagnato, M., Deborah, D., Namia, C.,
serious attempts should be made to screen BPD (Chanen et al., 2008a, Novella, L., Petrachi, M., 1997. Interrater reliability and internal consistency of the
2008b) and improve access to early treatment in women prisons. structured clinical interview for DSM-IV axis II personality disorders (SCID-II),
version 2.0. J. Personal. Disord. 11, 279284.
Particular attention should be paid to possible risk factors especially National Bureau of statistics of China, 2013. China Statistical Yearbook. China Statistical
comorbid psychiatric disorders. Press, Beijing.
National Bureau of statistics of China, 2014. China Statistical Yearbook. China Statistical
Press, Beijing.
Conict of Interest Paris, J., 2008. Personality disorders over time: precursors, course, and outcome.
American Psychiatric Pub..
The authors declare no conict of interest related to the topic of this Paris, J., 2009. The treatment of borderline personality disorder: implications of research
on diagnosis, etiology, and outcome. Annu. Rev. Clin. Psychol. 5, 277290.
study.
Perry, J.L., Carroll, M.E., 2008. The role of impulsive behavior in drug abuse.
Psychopharmacology 200, 126.
Acknowledgment Quirk, S.E., Berk, M., Pasco, J.A., Brennan-Olsen, S.L., Chanen, A.M., Koivumaa-
Honkanen, H., Burke, L.M., Jackson, H.J., Hulbert, C., C, A.O., Moran, P., Stuart,
A.L., Williams, L.J., 2016. The prevalence, age distribution and comorbidity of
This study was partly funded by the National Natural Science personality disorders in Australian women. Aust. N. Z. J. Psychiatry.
Foundation of China (Number: 81571316; 81371500). The authors Rendu, A., Moran, P., Patel, A., Knapp, M., Mann, A., 2002. Economic impact of
thank all participants and prison ocers in Hunan Female Prison for personality disorders in UK primary care attenders. Br. J. Psychiatry 181, 6266.
Sansone, R.A., Lam, C., Wiederman, M.W., 2012. The relationship between illegal
their contribution to this study. behaviors and borderline personality symptoms among internal medicine
outpatients. Compr. Psychiatry 53, 176180.
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