Letter to Editor

Borderline personality disorder in the east

The diagnosis of borderline personality disorder (BPD) is one
that is generally accepted as valid by mental health professionals
all over the world. Despite the attention it receives in the west,
studies on eastern populations remain hard to come by, especially
in major healthcare databases this is illustrated in the literature
search below. Data from western studies show BPD to be a highly
distressing illness affecting 2% of the general population, and up to
20% of psychiatric inpatients. It is also is associated with a 50-fold
increase in suicide risk compared to the general population
(Bender et al., 2006), and a 24 fold increase in psychiatric
treatment than patients with a major depressive disorder. As
several epidemiological studies of depression and anxiety have
shown signicantly different prevalence rates across cultures
(Weissman et al., 1996; Bhui 1999; Prina et al., 2011), an
investigation into the literature on BPD in non-western cultures
was prompted, with the aim of determining whether similar
differences exist.
A national guideline for the management of BPD (NIHCE, 2009)
was consulted prior to performing the literature search. This
guideline cited only one eastern study (Pinto et al., 2000), which
reported a prevalence rate of 17% in patients who were assessed
using SCID-II after a suicide attempt. Two further papers are
quoted in Pintos paper the rst reported a prevalence rate of 10%
in Turkish psychiatric inpatients, using DSM-III-R criteria (Senol
et al., 1997); and the second, a multi-centre study done with the
purpose of assessing the International Personality Disorder
Examination (IPDE), reported BPD and antisocial personality
disorder as the most frequently diagnosed disorders in all fourteen
centres (n = 100/centre), with the exception of India and Kenya. It
is worth noting that only three of the fourteen centres were in non-
western countries (Loranger et al., 1994). Although the rst two
papers support nearly similar rates of BPD, the third would make a
case for difference prevalence rates.
A literature search was then performed using the following
databases on OvidSP (November 2011): Ovid MEDLINE(R),
Journals@Ovid Full Text, Embase, ERIC, and NHS Scotland journals
@ Ovid. All papers with borderline personality and prevalence
in their abstracts were identied. Exclusion criteria were studies
that were conducted in western countries (dened as all western
and central European countries and countries where the dominant
population is originally western or central European) and those
that did not report on the prevalence of borderline personality
disorder. All remaining studies were included.
This literature search resulted in 6 publications from the
following countries Bulgaria (Onchev and Ganev, 2000), Turkey
(Sar et al., 2003, 2006) and China (Qi et al., 2009; Leung and Leung,
2009; Wong et al., 2010).
The sample sizes were 160, 160, 240, 502, 1301 and 4110. Three
of the studies drew took samples from psychiatric patients
(inpatients, outpatients, those who had self-harmed) and the
remaining three sampled from a younger age group (college
students or high-school students). Reported prevalence rates
based on a various semi-structured interviews for BPD (Present
State Examination-10, Structured Clinical Interview for DSM IV,
Personality Diagnostic Questionnaire Revised, McLean Screening
Instrument for BPD) ranged from 1.4% in psychiatric outpatients in
Bulgaria (Onchev and Ganev, 2000) to 18.8% of patients after
episodes of self-harming (Wong et al., 2010).
The studies identied above are optimistic about the presence
of this disorder in the east, and a general similarity in prevalence
rates. This is further supported by previous empirical studies that
have measured the construct validity of BPD in Chinese adults
(Leung et al., 2007). However, samples were drawn from groups
that were likely to have BPD psychiatric patients, those who had
self-harmed, and young people where features such as emotional
lability, unstable interpersonal relationships and an unclear sense
of identity are common (NIHCE, 2009). This search was also limited
to journals indexed in the databases above. Although the problem
of indexation of psychiatric journals from developing countries is
well-known (Kieling et al., 2009), it was assumed that if a study
was large enough, it would tend to be published in journals
indexed in these larger databases. Heterogeneity in the sample and
measurement tools used also made it hard to compare groups.
Despite the results above, evidence from studies on other
psychiatric disorders show a different trend. A study on the
lifetime prevalence of depression in several different countries
using the Diagnostic Interview Schedule reported a prevalence
range of 1.5% in Taiwan to 16.4% in Paris (Weissman et al., 1996).
Similarly, Bhui (1999) found the prevalence of depression to be
signicantly different in two different cultural communities living
in the same area in the UK. Even within eastern countries (Prina
et al., 2011), an equally wide range was reported in a study on the
prevalence of anxiety among the elderly among patients in South
America, China and India. This sentiment is reected in the
exclusion of BPD from the recent edition of the Chinese
Classication of Mental Disorders, where it was replaced with
impulsive personality disorder as some aspects of BPD were
thought to be inapplicable to the local culture (Jie and Freedom,
2007). Nevertheless, there is a lot of overlap between the
diagnostic criteria (Zhong and Leung, 2009).
To conclude, there is evidence that this disorder exists in the
east, although studies on its prevalence are ambiguous. It would be
interesting to have a direct comparison between the prevalence of
BPD in the east vs. west, where samples are drawn from the general
population and similar diagnostic instruments are used. Prior to
this, a sound rst step would be to reach a consensus on the
differences between east and west that matter in terms of the
advancement of psychiatric care individualist vs. collectivist
cultures, lower-middle income countries vs. higher income
countries and the availability of resources are examples of this.
These differences are important as a mental illness in one culture is
not necessarily illness in another, as there can be wide variation in
Asian Journal of Psychiatry 6 (2013) 8081
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social norms (from which abnormal behaviour is dened) and
resources be it individual resilience, interpersonal support or
political drive.
Role of funding source
None required.
Conict of interest
None.
Acknowledgements
I would like to thank Dr. Michael Gotz for the interesting
discussions that we had concerning this topic.
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Eugene Kee Onn Wong
Department of Psychiatry, Forth Valley Royal Hospital, Stirling Road,
Larbert FK5 4WR, Scotland
E-mail address: Eugene.wongs@gmail.com (E.K.O. Wong)
19 January 2012
1 May 2012
14 May 2012
Letter to Editor / Asian Journal of Psychiatry 6 (2013) 8081 81