International Journal of Psychiatry in Clinical Practice, 2006; 10(4): 252 257

ORIGINAL ARTICLE

Naturalistic study on ICD-10 personality disorders

¨ SSLER JIRI MODESTIN, MARTIN NEUENSCHWANDER & WULF RO

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Department of Psychiatry, Burgho¨ lzli Hospital, University of Zurich, Switzerland

Abstract Objective. To study the frequency, socio-demography and comorbidity of ICD-10 personality disorders (PD), especially of emotionally unstable PD, in psychiatric inpatients. To test the subdivision of emotionally unstable PD in impulsive and borderline subtypes. Methods. Data on all psychiatric hospital stays in the Canton of Zurich in the years 1998 2002, routinely collected at the time of each patient’s hospitalization, were analysed. Results. PD was diagnosed in 10.2% of all inpatients, and the proportion of emotionally unstable PD diagnosis was 54.5%. There are considerable differences between impulsive and borderline personality disorders with respect to sex, age, employment status and comorbidity. Conclusion. Emotionally unstable PD is the most frequent PD in clinical settings. Its differentiation into impulsive and borderline subtypes is justified.

Key Words: Personality disorder, borderline, psychiatric inpatients, ICD-10

Introduction In different clinical settings [1 3], some 30 50% of all adult inpatients have been diagnosed with personality disorder (PD) and 18 43% with borderline personality disorder (BPD). In contrast, in community samples [4,5], the DSM prevalence rates ranged from 6 to 23% for any PD and from 0 to 5% for BPD. Thus, BPD is over-represented in psychiatric facilities, a finding which underlines its clinical importance: an increasing number of hospitalized patients are classified as borderline conditions [6]. BPD category predicts violent behavior [7] and represents an independent risk factor for suicide [8]. Besides, Cluster B PDs including BPD are frequently associated with other psychiatric disorders [9]. In ICD-10, PD corresponding to DSM BPD is outlined in clinical description and diagnostic guidelines as emotionally unstable PD and divided into impulsive and borderline subcategory [10]. The ICD-10 impulsive type has no DSM PD counterpart. Whereas there is abundant literature on DSM borderline PD, the ICD-10 emotionally unstable PD has only seldom been studied. We studied the frequency of ICD-10 PD diagnoses in a larger sample of psychiatric inpatients. We were interested in two topics:

1. The proportion of emotionally unstable PD compared to other PDs, and the comorbidity in both groups of patients. We hypothesised that emotionally unstable PD is the most frequent PD type and associated with more comorbid mental disorders than other PD types. 2. The subdivision of emotionally unstable PD into impulsive and borderline type. We tested this subdivision with the help of socio-demographic and clinical variables and the rate of comorbid mental disorders. We hypothesized that the differentiation of both subtypes is correct.

Subjects and methods Inpatients were traced and data obtained using a large data pool from the central psychiatric case register, which covers all eight psychiatric hospitals in the Canton of Zurich, Switzerland, a catchment area of about 1.2 million people. Since all hospitals are legally mandated to report psychiatric admissions and discharges to the register, all inpatient episodes within this catchment area are recorded. The database contains detailed information including diagnostic, treatment-related, and socio-demographic characteristics. All patients are diagnosed

Correspondence: J. Modestin, M.D., University of Zurich, Department of Psychiatry, Burgho¨lzli Hospital, Lenggstrasse 31, CH-8032 Zurich, Switzerland. Tel: /41 44 384 2670. Fax: /41 44 384 2718. E-mail: [email protected]

(Received 2 August 2005; accepted 28 January 2006) ISSN 1365-1501 print/ISSN 1471-1788 online # 2006 Taylor & Francis DOI: 10.1080/13651500600650067

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ICD-10 personality disorders according to ICD-10 [10]. Many inpatients receive multiple diagnoses. The hospital physicians in charge of the respective patients are responsible for the documentation. Diagnoses are approved by members of the staff, all of them certified psychiatrists with long professional experience. Data are collected in a standardized form, and completion of forms and consistency of information is regularly monitored. Data, therefore, are largely complete and can be regarded as reliable. Missing data, e.g. on previous housing situation and employment status, are due to the premature discharge of some patients, their refusal to communicate the data, or foreign patients’ insufficient knowledge of the local languages. Due to the regulations for data protection, the system does not make it possible to trace individual patients across the individual hospitals so that, except for first-ever admissions, we cannot differentiate between patients and admissions/discharges. Therefore, we concentrated on first-ever admissions. In the category ‘‘All admissions’’ the majority of patients figure more than once. For the purpose of this study, data covering the years 1998 2002 were extracted and evaluated; Pearson’s x2-test was used for categorical and the t -test for continuous variables. Results During the analysed 5-year period (1998 2002), a total of 40,111 inpatient episodes were registered; out of these, 9940 (24.8%) were first-ever admissions, the rest readmissions. Altogether, the ICD-10 discharge diagnosis of F 60 personality disorder was given in 4102 (10.2%) episodes, irrespective of whether it was the first/principle or additional diagnosis. Considering first-ever admissions exclusively, the proportion of the PD diagnosis was 6.7%. The diagnosis of F 60.3 of emotionally unstable PD was the most frequent diagnosis of a particular PD type. It was given in 54.5% of all patients, and in 41.7% of first-ever admissions diagnosed with PD.

Table I shows the distribution of all psychiatric inpatients diagnosed with PD according to PD type and differentiates between first-ever and all admissions: emotionally unstable PD diagnosis (F 60.3) was given in the majority of cases; the borderline subtype (F 60.31) was diagnosed 3.3 times more frequently in first admissions and 6.5 times more frequently in all admissions than the impulsive subtype (F 60.30). In some cases, the differentiation of emotionally unstable PD in the subtypes was not made. Incidentally, there are differences in the PD type distribution between first and all admissions: some PDs are more frequent among all admissions. In all patients with emotionally unstable PD only exceptionally  in 64 (2.9%) of 2237 patients  was another PD diagnosed, most frequently histrionic PD in 23 (1.0%) patients. In Tables II and III, only first-ever admissions are considered. Comparisons were carried out with regard to various socio-demographic variables, clinical variables, and comorbidity. In both tables, only significant differences are reported. In Table II, cases with emotionally unstable PD are compared with cases diagnosed with other PDs. In Table III, both subtypes of ICD-10 emotionally unstable PD, the impulsive and the borderline subtypes, are compared with each other. Altogether, 46% of first-ever admissions diagnosed with PD were actively employed; in contrast, only 29% of all admissions diagnosed with PD were actively employed, which indicates a worsening of their psychosocial situation. Discussion The most prominent results of our study can be summarized as follows: ICD-10 emotionally unstable PD, and especially its borderline subtype, is by far the most frequently diagnosed PD in a psychiatric inpatient setting, accounting for over half of all PD diagnoses. In one-third of these cases, no additional diagnosis was given, whereas there were no patients with another PD without a comorbid

Table I. Distribution of PD types among psychiatric inpatient discharges diagnosed with PD. ICD-10 code F60 F 60.0 F 60.1 F 60.2 F 60.3 .30 .31 F 60.4 F 60.5 F 60.6 F 60.7 F 60.8 F 60.9

PD type All types Paranoid Schizoid Dissocial Emotionally unstable Impulsive Borderline Histrionic Obsessive-compulsive Anxious-avoidant Dependent Other specific NOS

Percentages are given in parentheses.

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First-ever admissions 662 29 16 20 276 48 158 36 18 48 87 124 28

(100) (4) (2) (3) (42) (7) (24) (5) (3) (7) (13) (19) (4)

All admissions 4102 86 81 187 2237 247 1594 215 66 175 359 647 112

(100) (2) (2) (5) (55) (6) (39) (5) (2) (4) (9) (16) (3)

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Table II. Comparison of emotionally unstable PD and other PDs. Significance Emotionally unstable PD n1 /276 (100)

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Sex: women Age at discharge (years): Mean9/SD

Other PDs n2 /386 (100)

x2/t * (df)

P

190 (69) 30.69/11.4

168 (44) 39.49/14.6

40.52 (1) 8.65* (654.8)

B/.001 B/.001

Professional qualification:1 None Basic Higher/university

109 (43) 112 (44) 34 (13)

98 (28) 178 (50) 79 (22)

17.61 (2)

B/.001

Comorbidity: F13 Sedative use disorder F2 Any schizophrenia spectrum disorder F3 Any affective disorder F40 Phobic disorder F43 Stress/adjustment disorder Any comorbidity

5 7 71 1 37 182

20 28 152 15 77 386

(2) (3) (26) (B/1) (13) (66)

(5) (7) (39) (4) (20) (100)

3.86 7.15 13.43 8.47 4.83 153.22

(1) (1) (1) (1) (1) (1)

.049 .007 B/.001 .004 .028 B/.001

Percentages are given in parentheses. 1 n1 /255 and n2 /355 for this variable.

diagnosis (see Table II). Incidentally, these figures remain the same irrespective of whether the first or all admissions are considered. The differentiation of emotionally unstable PD into impulsive and borderline subtypes appears to be justified: the majority of patients with impulsive PD were men, often also diagnosed with substance use disorder, whereas the vast majority of patients with borderline PD were young women, more frequently unemployed due to disability and often with comorbid affective or eating disorders. Viewing these substantial differences, it appears even questionable to classify both sub-

types  i.e. impulsive and borderline  under the same category of emotionally unstable PD. PD prevalence Altogether, in 7% of all first-ever admissions and 10% of all admissions a PD diagnosis was given. The data presented in this study were obtained routinely in a clinical setting by treating psychiatrists, and as such they are based on clinical unstructured interviews. Also, as the ICD-10 system does not ask for diagnoses on different axes, the treating physician is

Table III. Emotionally unstable PD: comparison of impulsive and borderline subtypes. Significance Impulsive subtype F 60.30 n1 / 48 (100)

Borderline subtype F 60.31 n2 /158 (100)

x2/t * (df)

P

17 (35) 32.29/10.9

134 (85) 27.49/8.4

43.41 (1) 3.15* (204)

B/.001 .002

Marital status: Single Married/widowed Separated/divorced

26 (55) 13 (28) 8 (7)

114 (72) 21 (13) 23 (15)

6.16 (2)

.046

Employment status: Employed Unemployed Disability

25 (53) 15 (32) 7 (15)

71 (45) 27 (17) 57 (37)

9.51 (2)

.009

21 (49) 42.69/50.8

42 (29) 72.99/93.0

6.16 (1) 2.91* (146)

.013 .004

23 (48) 6 (12) 1 (2)

45 (28) 51 (32) 17 (11)

6.29 (1) 7.20 (1) 3.48 (1)

.012 .007 .062

Sex: women Age at discharge (years): Mean9/SD

Involuntary admission Duration of index-hospitalization (days): Mean9/SD Comorbidity: F1 Any substance use disorder F3 Any affective disorder F50 Eating disorder

Percentages are given in parentheses. n1 /43 48; n2 /147 158 for individual variables.

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ICD-10 personality disorders not required to give a judgment on the patient’s personality in every case. Therefore, due to the weaknesses of our diagnostic procedure, PDs will be under-diagnosed in our population, and our corresponding data do not represent ‘‘true’’ prevalences. Standard clinical assessment yields lower prevalence rates than structured interviews [11]. Indeed, lower proportions of PD inpatients were identified in our study, compared with the studies quoted above [1 3], using specific diagnostic instruments. The prevalence of DSM BPD was estimated to be 50% among psychiatric inpatients with a diagnosis of PD [12]. Correspondingly, emotionally unstable PD was by far the most frequently diagnosed PD in our study, accounting for 42% of PD diagnoses among first-ever admissions and 55% of PD diagnoses among all admissions (see Table I). Our hypothesis that emotionally unstable PD is the most frequent PD type among inpatients was fully confirmed. In the general population [4,13] and among primary care patients [9], impulsive PD appears more frequent than borderline PD. The opposite is true for psychiatric inpatients, as demonstrated by our results: borderline PD was diagnosed 3.3 times more frequently than impulsive PD when first-ever admissions, and 6.5 times more frequently when all admissions were considered. The comparison of the two latter figures points to a substantially higher readmission rate of patients with borderline PD  at the expense of paranoid, anxious-avoidant, obsessive-compulsive, and dependent PD in our population. Quite obviously, there are differences in the rehospitalization rate of individual PDs, borderline PD seeming to be the highest. On the other hand, it cannot be excluded that ‘‘problem patients’’ with increasing disability and tendency for re-admissions more frequently received the borderline diagnosis. Emotionally unstable PD versus other PDs Comparing emotionally unstable PD with other PDs (Table II), there is a clear preponderance of women and of younger patients due to a high proportion of women and younger age patients in the borderline PD subtype. Also, patients with emotionally unstable PD tend to be less well educated. As predicted, there were differences in the rate of comorbidity; however, in the opposite direction than expected. Whereas a comorbid diagnosis was given to two-thirds of patients with emotionally unstable PD, there was no single patient with another PD without additional diagnosis. Specifically these were some substance use, schizophrenia spectrum, affective, phobic and stress/adjustment disorders  all of which were more frequently diagnosed together with other PDs. Again, even though we cannot exclude the non-structured diagnostic procedure to be at least partially responsible for this unexpected find-

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ing, there may also be other explanations: the clinical picture of emotionally unstable PD is probably prominent enough to ‘‘stand alone’’; whereas in other PDs, the diagnosis is more often an additional rather than a principle one. Moreover, other PDs may indeed only exceptionally be seen with exclusive PD-inherent behavioral pathology, that would be pronounced enough to require hospitalization. In the literature, a lot of attention has been paid to the comorbidity of BPD, mainly with affective disorders [14,15]. Nevertheless, other PDs are also frequent in affective disorders [16], and the prevalence of affective disorders was not significantly different in BPD as compared with other PDs [17]. In contradiction to other findings [18 20], comorbid PD was only exceptionally diagnosed in patients with emotionally unstable PD in our population. This reflects clinical diagnostic reality: obviously only the most prominent PD is diagnosed. Emotionally unstable PD: impulsive versus borderline subtype The subdivision in ICD-10 of emotionally unstable PD into impulsive and borderline subtype is unique. Whereas the impulsive PD diagnosis was already used in ICD-9 as excitable type [21] and by Kurt Schneider as explosive type [22], the borderline type was inferred from the DSM. The classification of both subtypes in the same category appears questionable and the corresponding data basis is weak. Still, Whewell et al. [23] identified two factors by means of a factor analysis of 288 self-ratings of the DSM-III-R BPD diagnostic criteria: one factor closely corresponded with the borderline, the other factor with the impulsive subtype of ICD-10. Nevertheless, other results favor a unifactorial structure of the  more or less coherent  DSM borderline PD construct [21,24 26]. Comparing ICD-10 and DSM-III-R PD categories from another perspective, the correspondence of ICD impulsive PD with DSM BPD was poor, and none of the ICD-10 impulsive criteria were prototypic for any DSM-III-R PD [27]. In contrast, there may be a relationship with impulse control disorders, specifically to intermittent explosive disorder. A link between BPD and impulse disorders has been claimed [28,29] Comparing both types of ICD-10 emotionally unstable PD, the impulsive type and the borderline type (see Table III)  the subdivision into both subtypes not having been carried out in a number of cases due to the diagnostic deficiencies  is a topic rarely dealt with in the literature. The results show that the majority of patients with impulsive PD were men, the majority of patients with borderline PD were women. Borderline PDs tend to be younger, single and unable to work. In spite of their more frequent involuntary admissions, impulsive PDs stayed in the psychiatric hospital for a shorter time.

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Also, there are significant differences between both subtypes with respect to comorbidity: patients with impulsive PD were more frequently additionally diagnosed with substance use disorders, patients with borderline PD with affective and eating disorders. The latter findings are not unexpected: there is a considerable overlap between DSM BPD and affective disorders [14 16] and a biological similarity between ICD-10 borderline PD and major depression [30]. DSM BPD comorbidity with eating disorders is also well known [31,32]. There is a cooccurrence of BPD with substance use disorders [33,34], and, in comparison with other PDs, it is more frequent in male and not in female patients [35].

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Key points . In routine clinical practice, 10% of all psychiatric inpatients and 7% of first-ever admissions were diagnosed with PD according to ICD-10 . The diagnosis of emotionally unstable PD was the most frequent PD diagnosis, given to 55% of all patients and to 42% of first-ever admissions diagnosed with PD . The emotionally unstable borderline subtype was diagnosed more frequently than the impulsive subtype, mostly in young women with a comorbid affective or eating disorder . Significant differences between the borderline and impulsive subtypes were found, questioning their classification under the same diagnostic label of emotionally unstable PD . In clinical practice, only the most prominent PD tends to be diagnosed and, in contrast to emotionally unstable PD, other PDs were diagnosed only in the presence of comorbid axis I disorders

The authors have no conflict of interest with any commercial or other associations in connection with the submitted article.

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Statement of interest

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Naturalistic study on ICD-10 personality disorders.

Objective. To study the frequency, socio-demography and comorbidity of ICD-10 personality disorders (PD), especially of emotionally unstable PD, in ps...
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