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Psychiatry Research 250 (2017) 200203

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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,
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
Suzhou Psychiatric Hospital, The Aliated Guangji Hospital of Soochow University, Suzhou, China
University of Notre Dame Australia / Marian Centre, Perth, Australia
School of Psychiatry & Clinical Neurosciences, University of Western Australia, Perth, Australia
Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Macao SAR, China


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: (X.-P. Wang), (Y.-T. Xiang).
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

2. Methods were conducted by univariate analysis (two independent samples test

and chi-square test), as appropriate. Multiple logistic regression
2.1. Subjects and study site analysis with the enter method was used to examine the independent
associations between BPD and demographic and clinical characteris-
This was a cross-sectional study conducted in Hunan provincial tics. BPD was entered as dependent variable, while demographic and
Female Prison between December 1, 2012 and November 30, 2013. clinical characteristics that signicantly diered in the above univariate
This prevalence study of BPD in female prison inmates was initiated by analyses were entered as independent variables. The signicance level
the Center-South University Mental Health Research Institution, was set at 0.05 (two-tailed).
China. Eligible participants included all inmates in this female prison
if they were of Chinese ethnicity, uent in Chinese language, and were 3. Result
able to communicate adequately and comprehend the purpose and
contents of the study. Participation in the study was voluntary and all Of the eligible 2916 female inmates, 2709 fullled the study criteria
study participants provided written informed consent. The study and completed the study, giving a participation rate 92.9%. The lifetime
protocol was approved by the Bureau of Prisons in Hunan Province, prevalence of BPD was 10.6% (288/2709; 95% condence interval [CI]:
the Hunan Female Prison and the Clinical Research Ethics Committee 9.511.9). In both the BPD and Non-borderline personality disorder
of the Center South University. (NBPD) groups the most frequent crime was drug tracking (52.4%
and 35.2%, respectively) followed by homicide (11.8% and 16.7%,
2.2. Assessment instruments respectively). Table 1 shows the basic socio-demographic and clinical
characteristics of the whole study sample and the comparison between
Data on the socio-demographic and clinical characteristics were BPD and NBPD groups. Compared to those without BPD, female
collected using a standard form designed for this study during the two inmates with BPD were younger, had higher education level, and were
hour interview conducted by nine trained psychiatry research assis- more likely to be unmarried, unemployed, and having drug use,
tants. Records of major medical conditions in the various categories criminal history and more comorbid psychiatric disorders established
(ear/nose/throat, pulmonary, cardiovascular, gastrointestinal, muscu- by the MINI. In addition, family members of those with BPD were
loskeletal, neurological, endocrine, blood-lymphatic, dermatological more likely to have drug use and history of psychiatric disorders. There
and immune system diseases) were self-reported and conrmed with were no signicant dierences between two groups with regard to
family members, if they were available. personal monthly income, nancial perception and current criminal
The diagnosis of BPD according to DSM-IV (APA, 1994) was types.
established by administering the validated Chinese version of the Multiple logistic regression analysis revealed that younger age,
Structural Clinical Interview for DSM-IV (SCID) (Maei et al., 1997; unmarried marital status, higher education level, fewer major medical
Dai et al., 2006). The diagnostic assessment of lifetime comorbid conditions, more frequent personal and family members drug use,
psychiatric disorders including substance dependence, psychotic dis- more frequent comorbid psychiatric disorders and family history of
orders, major depression, bipolar disorder, anxiety disorder and psychiatric disorders were positively and independently associated with
posttraumatic stress disorder (PTSD) was conducted using the vali- BPD, accounting for 20.5% of the variance of BPD (p < 0.001)
dated Chinese version of the MINI, Version 5.0, to establish DSM-IV (Table 2).
diagnoses (Sheehan et al., 1998; Si et al., 2009).
4. Discussion
2.3. Data collection
This is the rst study to determine the lifetime prevalence and
An advertisement about this study was distributed by the prison correlates of BPD in female prison inmates in China with systemic
ocers to all inmates. Those who agreed to participate in this study diagnostic instruments. The prevalence of BPD in this study is 10.6%,
were screened for eligibility following a detailed explanation about the which is higher than the gures in the community (1.43.02%)
purpose, and consent for the study was obtained. The survey of their (Lenzenweger et al., 2007; Trull et al., 2010) in the USA and in clinical
socio-demographic and clinical characteristics was completed on a samples (5.8%) in China (Wang et al., 2007), but lower than the results
voluntary basis in a quiet room at the prison before they participated in among female prison samples in developed country, such as in Australia
the interview for the MINI and SCID. Information on female inmates (26%) (Tye and Mullen, 2006) and in the USA (54.5%) (Black et al.,
current oense and criminal history was collected by a review of the 2007). There are several possible reasons for such discrepancy across
police records. Index oences were divided into non-violent (e.g. studies. First, cultural and ethnic factors may contribute to the
drug tracking, theft, fraud, prostitution, blackmail or forgery) and dierences in prevalence of BPD. For example, a national survey in
violent crimes (e.g. homicide, assault, robbery, arson, kidnapping and the USA found that native Americans (5.0%) and Blacks (3.5%) had 3 or
abduction) for the analyses. Information about family members, such 4 fold higher prevalence of BPD than Asians (1.2%) (Tomko et al., 2014).
as drug use and history of psychiatric disorders, were also collected in Second, dierent types of prison, such as closed (20%) and semi-open
the interview and later conrmed with the families, if they were ones (35%), usually have dierent prevalence of BPD (Black et al., 2007).
available. Third, dierent diagnostic instruments for BPD were used thus leading
Prior to the commencement of the study, all interviewers were to variable estimation of the rates of BPD.
trained using a standard training package and attended an inter-rater Similar to previous ndings in other countries (Grant et al., 2008;
reliability exercise. The interviewers' MINI and SCID diagnoses were Paris, 2009; Tomko et al., 2014), BPD is independently associated with
compared with the best estimate clinical diagnoses. The kappa values a number of demographic and clinical characteristics, such as younger
for the nine interviewers ranged from 0.86 to 0.95, suggesting that the age, unmarried marital status, more frequent unemployment and drug
diagnostic agreement was acceptable. use. Age was found to be negatively related with BPD in this study. It is
plausible that younger adults are likely to have more impulsivity, a core
2.4. Statistical analyses clinical features of BDP, than older adults (Galvan et al., 2007; Leshem
and Glicksohn, 2007), which can lead to criminal behavior. Drug use is
Data analyses were used by the Statistical Product and Service often viewed as an accompanying feature of impulsivity in BPD. Earlier
Solutions (SPSS) 21.0. The comparison between the BPD and non-BPD studies found that persons with impulsive tendencies often have higher
groups with respect to social-demographic and clinical characteristics risk of drug use (Perry and Carroll, 2008; De Wit, 2009). Unstable

X.-M. Zhu et al. Psychiatry Research 250 (2017) 200203

Table 1
Socio-demographic and clinical data of the study sample.

The whole sample NBPD BPD Statistics

(n=2709) (n=2421) (n=288)

N % N % N % X2 df p

Married 1170 43.2 1096 45.3 74 25.7 40.2 1 < 0.001

Educational Level 13.4 2 0.001
Illiteracy/primary school 1000 36.9 922 38.1 78 27.1
Junior middle school 1049 38.7 922 38.1 127 44.1
Senior middle school and above 660 24.4 577 21.3 83 28.8
Unemployeda 1166 43.0 995 41.1 171 59.4 35.0 1 < 0.001
Financial perception 1.1 2 0.58
poor 1565 57.8 1404 58.0 161 55.9
normal 964 35.6 854 35.3 110 38.2
well 180 6.6 163 6.7 17 5.9
Personal monthly income (yuan) 3.8 1 0.051
1000 1501 55.4 1357 56.1 144 50.0
> 1000 1208 44.6 1064 43.9 144 50.0
Drug use in family members 207 7.6 165 6.8 42 14.6 22.0 1 < 0.001
Family history of psychiatric disorders 163 6.0 131 5.4 32 11.1 14.7 1 < 0.001
Criminal historyb 184 6.8 153 6.3 31 10.8 8.0 1 0.005
Current oense 1.2 1 0.27
Non-violent 1861 68.7 1655 68.4 206 71.5
Violent 848 31.3 766 31.6 82 28.5
Major medical conditions 1408 52.0 1288 53.2 120 41.7 13.7 1 < 0.001
Personal drug use 701 25.9 526 21.7 157 60.8 204.4 1 < 0.001
Lifetime comorbid psychiatric disorders assessed with the MINI 1795 66.3 1539 63.6 256 88.9 73.8 1 < 0.001

Mean SD Mean SD Mean SD T df p

Age (years) 39.8 10.3 40.4 10.3 34.6 8.9 7.6 2707 < 0.001

1USD=6 yuan; BPD=borderline personality disorder; MINI=Chinese version of International Neuropsychiatric Interview; NBPD=Non-borderline personality disorder.
Being unemployed prior to their incarceration.
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
Being unemployed prior to their incarceration. medical conditions. Unexpectedly, there was a negative relationship
Past crimes prior to their incarceration. between major medical conditions and BPD in this study, for which we

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
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several methodological limitations. First, only inmates in Hunan clinical trajectory of patients with borderline personality disorder. Pers. Ment.
provincial Female Prison were included, therefore the ndings could Koenig, J., Rinnewitz, L., Parzer, P., Resch, F., Thayer, J.F., Kaess, M., 2016. Resting
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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
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Lenzenweger, M.F., Lane, M.C., Loranger, A.W., Kessler, R.C., 2007. DSM-IV personality
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version 2.0. J. Personal. Disord. 11, 279284.
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Conict of Interest Paris, J., 2008. Personality disorders over time: precursors, course, and outcome.
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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.
Perry, J.L., Carroll, M.E., 2008. The role of impulsive behavior in drug abuse.
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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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