Borderline personality disorder among jail inmates: how common and how distinct?

Author:Warden, Rebecca

Although borderline personality disorder (BPD) is rarely discussed in the forensic or correctional literalure, a remarkably high percentage of jail and prison in mates suffer from this disorder, which is typically chronic and debilitating. This article describes the characteristics of BPD and contrasts it with psychopathy, another disorder assumed to be closely related. The authors estimate the prevalence of these disorders in a large sample of male and female jail inmates held on felony charges and present evidence showing that these are distinct disorders of personality, likely reflecting unique motivations and needs. Implications for effective management and treatment of inmates with BPD also are discussed.

What is BPD?

BPD is characterized by marked impulsivity and pervasive instability of affect, self-image and interpersonal relationships (American Psychiatric Association, 2000). High rates of substance abuse (Hatzitaskos et al.. 1999; McCann, Ball and Ivanoff. 2000), antisocial activity (Coid, 1993) and behaviors aimed at harming the self (Wilkins and Coid, 1991) or others (Hernandez-Avila et al., 2000) have been associated with BPD. Emotional instability is a hallmark of BPD. As a consequence, individuals with BPD are at elevated risk for involvement in the criminal justice system. Whereas prevalence rates for BPD in the community are 1 percent to 2 percent (Kraus and Reynolds. 2001), rates among both male and female inmates have been estimated at 12 percent to 30 percent (Black et al, 2007; Douglas et al. 2007; Jordan et al., 1996; Singleton et al., 1998; Trestman et al., 2007). In fact, the prevalence of BPD in correctional settings is typically higher than in psychiatric in-patient sellings (about 20 percent), and more than double that of out-patient mental health clinics (about 10 percent) (American Psychiatric Association). Thus, it is important for those who work with inmates to understand BPD as a distinct disorder and to recognize that some "bad behavior" in correctional settings may be driven by this mental illness and may not be entirely volitional. Awareness of the behavioral manifestations of BPD, and the dysfunctional emotions and cognitions behind these behaviors, can lead to more effective strategies for managing and treating these individuals during their incarceration. Ideally, a better understanding of the scope and implications of BPD will stimulate development of programs to treat inmates with BPD and facilitate I heir successful reintegration into the community upon release.

What is Psychopathy?

In the current study, the constructs of BPD and psychopathy are emphasized (Hare. 1991). Psychopathy is related to, but distinct from, the Diagnostic and Statistical Manual of Mental Disorders' (DSM-1V) diagnosis of antisocial personality disorder. This disorder is characterized by persistent involvement in anti-social behavior, beginning in childhood or adolescence, and includes behavioral symptoms such as impulsivity, dceeitfulness, criminal activity and aggressiveness. Most incarcerated offenders (50 percent to 80 percent) have behavioral histories that meet diagnostic criteria for anti-social personality disorder, whereas a smaller subgroup (15 percent to 30 percent) meets criteria for psychopathy (Hare, 1991). Psychopathy is a more severe disorder represented by a cluster of personality traits in addition to the anti-social behaviors characteristic, of antisocial personality disorder. The "gold standard" for assessing psychopathy is Hare's Psychopathy Checklist-Revised (PCL-R; I Iare, 1991). In fact, the PCL-R has come to define the construct of psychopathy in recent years. The PCL-R yields a total psychopathy score as well as two moderately correlated factor scores. Factor 1 assesses a personality style defined by glihness and superficiality, egocentric grandiosity, deceit and manipulation, lack of remorse and empathy, and shallow emotions in general. Factor 2 assesses a chronically unstable and anti-social lifestyle, focusing heavily on criminal and other problematic behaviors characteristic of anti-social personality disorder.

Notably, individuals who meet criteria for psychopathy score high on both factor 1 (psychopathic personality) and factor 2 (anti-social lifestyle), whereas those who meet criteria for anti-social personality disorder (the majority of incarcerated offenders) exhibit behaviors largely represented by factor 2 of the PGL-FL with or without the distinct personality characteristics that are the hallmark of psychopathy. Stated another way. there is very little personality in antisocial personality disorder, as defined in the DSM-IV. Although the DSM-IV states that lack of empathy. inllai: cl self-appraisal and superficial chan [much less than] are features that have commonly been included in traditional conceptions of psychopathy and may be particularly distinguishing of antisocial personality disorder in prison or forensic settings where criminal, delinquent or aggressive acts are likely to be nonspecific," the actual diagnostic criteria are largely behavioral and do not require such personality features. Anti-social personality disorder is generally diagnosed lor anyone with a history of significant socially deviant, anti-social behavior stretching back to at least age 14. As discussed by Blackburn (1988) and many others (Cooke and Michie, 200f; Hare, Hart and Harpur. 1991; Lilienfeld. 1994; Lilienfeld, Purccll and Jones-Alexander, 1997; Skeem and Mulvey. 2001; Skeem, Mulvey and Grisso. 2003). there are many factors that may cause a person to engage in anti-social behavior as an adolescent and to persist in such behavior into adulthood--for example, drug addiction, mental illness, personality characteristics, poverty, socialization and role models. Psv-chopathic personality is only one such factor, neither necessary nor sufficient for a diagnosis of anti-social personality disorder.

Anti-social personality disorder, then, may be useful as a tool for prospective risk assessment; persistent anti-social behavior is apt to predict future anti-social behavior. However, it is less useful in understanding the influence of personality, distinct forms of mental illness and associated motivations on anti-social behavior. For these reasons, the authors focus on psychopathy as more narrowly defined by Hare (1991) as a disorder of behavior and personality.

BPD and Psychopathy Among Offenders

BPD is characterized by many of the behavioral features of psychopathy, including lack of inhibition, impulsivify, drug use and promiscuous sexual behavior (Kraus and Reynolds. 2001). Both psychopathy and BPD have been found to be predictive of criminal activity in men and women (Hart and Hare, 1997; Hare et al., 2000: Komarovskaya, Loper and Warren, 2007; Tresfman et al., 2007). Not surprisingly, empirical evidence points to moderate comorbidity between BPD and psychopathy in men's prison populations (Douglas et. al., 2007: Stalenhein and von Knorring, 1996). BPD and psychopathy have also been found to coexist in women's prison populations (Hochhausen, Lorenz and Newman. 2002: Salekin, Rogers and Sewell. 1997). However, each of these studies used unidi-mcnsional indicators of BPD, many employed modest samples and none of the studies considered both male and female inmates using the same methods.

Although defined as a discrete diagnostic category in the DSM-IV (American Psychiatric Association. 2000). there is ample evidence that symptoms of BPD arc arrayed along a continuum. The current study assessed symptoms of borderline personality using the Personality Assessment Inventory (PAI: Morey, 1991). Research demonstrates that scores on the PAI borderline features scale converge with clinicians" diagnoses of BDP based on DSM-IV criteria. In a sample of 63 outpatients (BPD base rate 0.72), a T-score of 65 was deemed optimal, with 0.91 sensitivity, 0.79 specificity, 0.94 positive predictive power, 0.73 negative predictive power and an overall correct classification rate of 0.89 vis-a-vis the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) diagnoses (Jacobo et al.. 2007). Concordance between PAI-derived and clinician-derived classification is equivalent to the concordance between clinicians using DSM-IV criteria. In a recent study (Critchfield, Levy and Clarkin, 2007), trained clinicians using the SCID-II agreed 87 percent of the time on a diagnosis of BPD (base rate 0.76). Thus, a cutscore of 65 on the PAI borderline features scale agrees just as well with a clinician-derived SCID-II diagnosis as two independent SCID-II assessments agree with each other.

Psychopathy is similarly used most often as a diehotomous clinical variable, with scores above 30 on the PCL-R and scores above 18 on the Pyseopathy Checklist: Screening Version (PCL: SV; Hart. Cox and Hare. 1995) indicative of psychopathy (and scores below these cut - scores indicative of an absence of psychopathy). Here too, however, there is abundant evidence that psychopathy reflects a true continuum. Recent taxometric analyses have provided no evidence of an underlying psychopathy taxon (Edens. Marcus and LilienfelcL 2006; Guay, Ruscio and Knight, 2007; Marcus, John and Edens. 2004). In the current study, psychopathy and BPD were analyzed both as continuous variables and as diehotomous. diagnostic variables. The latter is presented to maintain consistency with clinical practice, estimating diagnostic comorbidity. In addition, analyses of BPD...

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