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Immigrants and borderline personality disorder at a psychiatric emergency service

  • J. C. Pascual (a1), A. Malagón (a2), D. Córcoles (a2), J. M. Ginés (a2), J. Soler (a1), C. García-Ribera (a2), V. Pérez (a1) and A. Bulbena (a3)...

Abstract

Background

Several studies have suggested that immigrants have higher rates of psychiatric emergency service use and a higher risk of mental disorders such as schizophrenia than indigenous populations.

Aims

To compare the likelihood that immigrants (immigrant group) v. indigenous population (indigenous group) will be diagnosed with borderline personality disorder in a psychiatric emergency service and to determine differences according to area of origin.

Method

A total of 11 578 consecutive admissions over a 4-year period at a tertiary psychiatric emergency service were reviewed. The collected data included socio-demographic and clinical variables and the Severity of Psychiatric Illness rating score. Psychiatric diagnosis was limited to information available in the emergency room given that a structured interview is not usually feasible in this setting. The diagnosis of borderline personality disorder was based on DSM–IV criteria. Immigrants were divided into five groups according to region of origin: North Africa, sub-Saharan Africa, South America, Asia and Western countries.

Results

Multivariate statistical logistic regression analysis showed that all subgroups of immigrants had a lower likelihood of being diagnosed with borderline personality disorder than the indigenous population independently of age and gender. Furthermore, the rates of borderline personality disorder diagnosis were considerably lower in Asian and sub-Saharan subgroups than in South American, North African, Western or native subgroups.

Conclusions

Our results showed that in the psychiatric emergency service borderline personality disorder was diagnosed less frequently in the immigrant group v. the indigenous group. Our results do not support the concept of migration as a risk factor for borderline personality disorder.

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Copyright

Corresponding author

Dr J.C. Pascual, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Avenida Sant Antoni M. Claret, 167. 08025 Barcelona, Spain. Email: jpascual@hsp.santpau.es

Footnotes

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Declaration of interest

None. Funding detailed in Acknowledgements.

Footnotes

References

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14 Paris, J. Cultural factors in the emergence of borderline pathology. Psychiatry 1996; 59: 185–92.
15 Martin-Santos, R, Fonseca, F, Domingo-Salvany, A, Ginés, JM, Ímaz, ML, Navinés, R, Pascual, JC, Torrens, M. Dual diagnosis in the psychiatric emergency room in Spain. Eur J Psychiatr 2006; 20: 147–56.
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Immigrants and borderline personality disorder at a psychiatric emergency service

  • J. C. Pascual (a1), A. Malagón (a2), D. Córcoles (a2), J. M. Ginés (a2), J. Soler (a1), C. García-Ribera (a2), V. Pérez (a1) and A. Bulbena (a3)...
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eLetters

Author�s reply. Immigration and Borderline Personality Disorder: Unlikely association

Juan Carlos Pascual, Psychiatrist
19 February 2009

We thank Dr. Mushtaq for his comments on our article relating to the incidence of borderline personality disorder amongst immigrant patients admitted to a psychiatric emergency service (1). While we agree with his comment that it is unlikely that immigration could be a risk factor for developing borderline personality disorder (BPD), we think that this issueis still open to debate.

Firstly, other authors such as Paris (2) have suggested that the process of migration from traditional societies to Western countries couldresult in the development of BPD in individuals who did not present any symptoms in their country of origin. Paris considered that although individuals could have a biological predisposition to this disorder, such as an innate affective instability, the structure of traditional societiestends to suppress the kind of psychopathology seen in BPD. Once these patients emigrate to Western countries, this socio-cultural suppression disappears (2). In contrast, Tyrer et al. and Balaydier et al. observed a lower incidence of personality disorders in immigrant patients admitted topsychiatric emergency services (3,4). Likewise, in a previous study that was not centred on an immigrant population, we found that patients with BPD were less likely to be immigrants (5). For this reason, we performed an exploratory study (ie without an initial hypothesis) to examine whetherthere really was an association between immigration and BPD, where immigration could either be a risk factor or have a “protective” effect (1). Despite the fact that, in our opinion we observed a “protective” association for immigration on the development of BPD, our results do not invalidate Paris’s hypothesis. In Spain, immigration is a relatively new phenomenon, and the majority of patients we evaluated were adults from poorer countries who were not yet totally immersed in Western culture. It is possible that in younger immigrants (whose personality has not yet beentotally consolidated) or in second-generation immigrants, a higher prevalence of BPD could eventually be observed, as suggested by Paris (2).

Secondly, another important point of our study is that the immigrant sample must not be considered as a homogeneous group, since important differences exist between the subgroups of immigrants, according to their geographical origin. For instance, patients from sub-Saharan Africa and Asian countries were more than seven times less likely than other immigrants to be diagnosed of BPD. Therefore, it could be suggested that certain cultural differences in these regions, for example a greater tolerance to suffering, could be useful factors to prevent the developmentof this disorder. The identification and analysis of these “protective” cultural factors could offer future tools to prevent the appearance of BPDin Western societies.

We would also like to highlight that although we share Dr. Mushtaq’s opinion that it is unlikely that immigration may be a risk factor for BPD,the empirical evidence so far is not only scarce but also somewhat contradictory and with important methodological limitations. In fact, ourown study presents some of these limitations. To confirm our findings, more methodologically rigorous studies would be necessary.

References:

1. Pascual JC, Malagón A, Córcoles D, Ginés JM, Soler J, Garcia-Ribera C, Pérez V, Bulbena A. Immigrants and borderline personality disorder at a psychiatric emergency service. British Journal of Psychiatry2008; 193: 471-476.

2. Paris J. Cultural factors in the emergence of borderline pathology. Psychiatry. 1996; 59(2): 185-92.

3. Tyrer P, Merson S, Onyett S, Johnson T. The effects of personalitydisorder on clinical outcome, social networks and adjustment: a controlledclinical trial of psychiatric emergencies. Psychol Med 1994; 24: 731 –40.

4. Baleydier B, Damsa C, Schutzbach C, Stauffer O, Glauser D. Comparison between Swiss and foreign patients’ characteristics at the psychiatric emergencies department and the predictive factors of their management strategies. Encephale 2003; 29: 205 –12.

5. Pascual JC, Córcoles D, Castaño J, Ginés JM, Gurrea A, Martín-Santos R, Garcia-Ribera C, Pérez V, Bulbena A. Hospitalization and pharmacotherapy for Borderline Personality Disorder in a Psychiatric Emergency Service. Psychiatric Services, 2007; 58: 1199-1204.

Authors: Juan C. Pascual, Joaquim Soler, Víctor Pérez.

Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona. CIBER-SAM.Email: jpascual@santpau.es

Declaration of interest: None
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Conflict of interest: None Declared

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Unlikely association

Salman A Mushtaq, Staff Grade Psychiatrist
24 January 2009

An interesting study which shows a lot of effort by researchers, who reviewed thousands of cases, despite the limitations of research methodology. However I wonder what prompted the researchers to think that immigration could be a risk factor for borderline personality disorder?

Unlike functional illnesses such as depression and schizophrenia which can develop at any age and can have lots of predisposing factors, personality disorders develop during early years of childhood and adolescence and most of the personality traits are usually well established by adulthood.

Most of the immigrant groups in this study (1) are from developing orpoor countries and it’s not a surprise that lesser people from this group were diagnosed with borderline personality disorder as compared to the indigenous population. We know that the prevalence of personality disorders is greater in developed and western countries (2).

If we look at the features and diagnostic criteria for personality disorders, either using DSM-IV or ICD-10, we broadly see two main factors at the base of most of the symptoms. Poor coping mechanisms and maladaptive behaviours. Factors commonly seen in western and developed countries which contribute to such traits and learned behaviours are breakdown of community norms (3) such as lack of family cohesion, lack of social support network, dysfunctional families and child abuse. These are just a few factors without going into detail. Also, in developed countries as people enjoy more privileges, they tend totake less responsibility for their actions and expect more and more from the estate. We increasingly see more pressure on social services, rather than parents to account for the welfare of children.

This does not mean that borderline personality disorder is exclusive to west but in social context, we do see more reasons for people in the west to have such traits.

Given the aetiological factors that we are aware of, and the crucial age factor for borderline personality disorder, it’s not a surprise that immigration is not a risk factor for borderline personality disorder. An interesting study that confirms what was earlier suggested by Tyrer et al (4) and Baleydier et al (5), however I am not sure whether a similar studyin future would be useful, given that it is unlikely that immigration can be a risk factor for developing borderline personality disorder.

I do however, agree with the authors that future studies in younger immigrants and second generations who will be more influenced by the Western way of life are likely to be more interesting and helpful, especially in terms of clinical management.

DOI: None

References:

1.Pascual.J.C: The British Journal of Psychiatry (2008) 193: 471-476

2.Millon T. Sociocultural conceptions of the borderline personality.Psychiatr Clin North Am 2000; 23: 123 –36

3.Paris J. Social Factors in the Personality Disorders: A Bio psychosocial Approach to Aetiology and Treatment. Cambridge University Press, 1996

4.Tyrer P, Merson S, Onyett S, Johnson T. The effects of personalitydisorder on clinical outcome, social networks and adjustment: a controlledclinical trial of psychiatric emergencies. Psychol Med 1994; 24: 731 –40

5.Baleydier B, Damsa C, Schutzbach C, Stauffer O, Glauser D. Comparison between Swiss and foreign patients’ characteristics at the psychiatric emergencies department and the predictive factors of their management strategies. Encephale 2003; 29: 205 –12
... More

Conflict of interest: None Declared

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