ICD-10 lists five diagnostic criteria for borderline type (Table). All the five criteria are adopted from the DSM-BPD criteria set: uncertainty about self-image, intense and unstable relationships, fear of abandonment, recurrent acts of self-harm, and chronic feelings of emptiness. A EUPD-BPD patient must display at least three EUPD-impulsive symptoms plus any two of the five BPD symptoms. Comparison of the diagnostic criteria for BPD in DSM-IV-TR and ICD-10 reveals eight common symptoms: fear of abandonment (DSM criterion 1; ICD criterion 8), intense and unstable relationships (DSM criterion 2; ICD criterion 7), uncertainty about self-image (DSM criterion 3; ICD criterion 6), general impulsivity (DSM criterion 4; ICD criterion 1 and 4), recurrent threats of self-harm (DSM criterion 5; ICD criterion 9), affective instability (DSM criterion 6; ICD criterion 5), chronic feeling of emptiness (DSM criterion 7; ICD criterion 10), impulsive aggression (DSM criterion 8; ICD criteria 2 and 3).
There are, however, two major differences between the two systems in diagnosing BPD. First, according to the ICD-10-R, a patient must display (1) at least three EUPD-impulsive type symptoms plus (2) two or more of the five BPD symptoms in order to be diagnosed as EUPD-borderline type. In other words, some kinds of impulsivity is a necessary condition for diagnosing EUPD-borderline type. Second, the DSM system has introduced “transient, stress- related paranoid ideation or severe dissociative symptoms” (criterion 9) as one of the diagnostic symptoms for BPD since the DSM-IV, an item that is missing in ICD-10-R. Based on these differences in diagnostic criteria, BPD patients in Europe and the US may differ in at least two significant ways. First, while all EUPD-borderline patients must show some traits of impulsivity, some DSM-BPD patients may display no impulsive trait. Second, while EUPD- borderline patients will not display transient psychotic symptoms, some DSM-BPD patients, probably the most disturbed subgroup, may display transient psychotic features.
There is a groundswell of dissatisfaction with the name borderline itself. Some researchers argued that the term EUPD is more preferable than BPD as it frees the construct from its previous psychoanalytic theoretical baggage, and comes closer to capturing the crucial dimensions of BPD, namely, its affective instability and impulsivity.8,40 However, a computer search of all major databases for empirical studies on EUPD indicated that both the construct validity and clinical phenomenology of EUPD have not really been subject to empirical evaluation. At this moment, it is not clear which diagnostic system provides a better description of this clinical syndrome that we refer to as borderline. Nevertheless, clinicians in both Europe and the US seem to agree that there is a group of rather disturbed psychiatric patients who display a highly comparable clinical profile that deserve serious clinical attention.
The introduction of the BPD construct also met strong resistance in China. It was argued that the BPD diagnosis is a vague construct that lacks precise boundaries, and some of its diagnostic features (e.g., fear of abandonment, chronic feelings of emptiness) are not appropriate culturally when used in China.41 As a result, the CCMD-3 committee has adopted the diagnostic category of impulsive personality disorder (IPD) rather than BPD in its official nomenclature.6
CCMD-3 lists 10 diagnostic symptoms for IPD.6 A patient diagnosed as having IPD must display “affective outbursts” and “marked impulsive behavior”, plus at least three out of eight other symptoms (Table). Among the other eight symptoms, the first five are basically adopted from the EUPD-impulsive type symptoms: (1) unpredictable and capricious mood (EUPD criterion 5), (2) liability to outbursts of anger and violence (EUPD criterion 3), (3) inability to plan ahead or foresee likely future events and circumstances (highly comparable to EUPD criterion 1), (4) difficulty in maintaining any course of action that offers no immediate reward (EUPD criterion 4), and (5) quarrelsome behavior with others (EUPD criterion 2). The other three symptoms include (6) stormy and unstable interpersonal relationships (EUPD criterion 7), (7) unstable self-image (EUPD criterion 6), and (8) frequent deliberate self-harm (EUPD criterion 9), all adopted from the EUPD-borderline type symptoms, with the deletion of items concerning fear of abandonment and chronic feelings of emptiness. Judging from its diagnostic criteria, the CCMD-IPD construct is basically a hybrid of both the EUPD-IPD and EUPD-borderline symptoms. In that case, CCMD-IPD patients bear closer resemblance in clinical profile to the EUPD-borderline type than EUPD-IPD type patients. A computer search for empirical studies on CCMD-IPD revealed that the construct validity and clinical phenomenology of this diagnostic category have in fact never been subject to any systematic empirical evaluation. At this stage, it is safe to conclude that the diagnostic category of CCMD-IPD is based mostly on clinical opinions rather than empirical evidence. Systematic empirical research evaluating the construct validity and clinical phenomenology of IPD is clearly needed.
Clinicians in the United States, Europe, and China observe a comparable clinical syndrome that is characterized by a pervasive pattern of mood and impulse control problems. Different conceptualization of this syndrome results in different diagnostic rules and divergent diagnostic categories: DSM-BPD, ICD-EUPD, and CCMD-IPD. This paper compares the characteristics of these diagnostic categories and evaluates the empirical evidence related to each of these clinical constructs.
Among these diagnostic categories, DSM-BPD has the strongest empirical foundation. Research evidence indicates that the DSM-BPD criteria set represents a valid psychiatric diagnosis with a well-defined clinical picture, well-documented neurobiological and psychosocial correlates, and well-conceptualized etiological models.8,17,42,43 Evidence based effective treatments for BPD have also been documented.29-34 Many clinicians agreed that while the term “BPD' may be a misnomer, but it represents a diagnostic category of high clinical utility by virtue of the rich empirical information concerning its clinical presentation, etiology, course of development, and treatment response.8,17,40 As a result, ICD-10 has also included the borderline construct as a subtype of the EUPD diagnostic category in its nomenclature.5
The BPD diagnosis met strong resistance among clinicians in China. The committee of CCMD-3 rejected BPD as a valid clinical construct. Instead, CCMD-3 has adopted the diagnostic category of IPD, which is basically a hybrid of both the EUPD-IPD and EUPD-BPD type symptoms from the ICD-10. The rejection of BPD and the inclusion of IPD in CCMD-3 raise several important questions. First, decision to add or drop a diagnostic category should be based on solid empirical evidence, not pure clinical opinions. Is IPD an empirically valid clinical construct? Computer search for empirical studies related to IPD, either as defined by ICD-10 or by CCMD-3, indicated that its construct validity, clinical utility, epidemiology, etiology, or treatment outcomes have in fact never been subjected to systematic empirical evaluation. At this moment, it is safe to conclude that the decision to include IPD in both ICD-10 and CCMD-3 was based largely on clinical opinions rather than solid empirical evidence. Systematic research examining the construct validity and clinical phenomenology of IPD is undoubtedly needed.
Second, since CCMD-3 does not contain the BPD diagnosis, most clinicians and researchers in China are not familiar with this clinical construct. Can we then assume that there are no BPD patients in China? Chinese clinicians reported cases of BPD from time to time in clinical journals.44 Preliminary empirical studies examining the DSM-BPD criteria set also demonstrated good construct validity among Chinese psychiatric patients in China.36-39 Taken together, these observations suggest that BPD patients do exist in China and systematic research to study the characteristics of this special population is clearly needed.
Third, Luo (2005) argued that even though CCMD-3 does not have the BPD diagnosis, it contains a significant number of diagnostic symptoms for BPD.44 Comparison of the diagnostic criteria between CCMD-IPD and DSM-BPD indicates that six of the nine DSM-BPD diagnostic features (with the exception of feelings of chronic emptiness, fear of abandonment, and transient psychotic symptoms) are found in the CCMD-IPD diagnosis. Can we then assume that the CCMD-IPD diagnosis is able to capture most of those patients who might otherwise be diagnosed as BPD? This is an extremely important clinical question because the prevalence of BPD has been estimated to be at 1%-2% of the general population in the West.2,3 If this prevalence figure is generalizable to China, a country with 1.3 billion people, it means 13 to 26 million Chinese could be suffering from BPD. However, CCMD-3 states that over sixty percent of the IPD patients are males.6 DSM-IV-TR, on the other hand, indicates that the majority of BPD patients (70 to 75 percent) are females.1 These reverse sex ratios for IPD and BPD suggest that a significant number of female BPD patients in China might have never been properly diagnosed and treated under the current diagnostic system.
Apparently, whatever the problems with the BPD diagnosis, there are also problems with not diagnosing this disorder. Thus, should the construct of BPD be introduced in CCMD-4? The BPD construct has received sufficient empirical support, and has been accepted as valid diagnosis in both ICD-10 and DSM-IV-TR. Clinical professionals in China need to benefit from the large empirical literature bearing on this complex clinical problem. Moreover, globalization means we have to provide a worldwide common language so that clinicians from different countries can learn from each other. Based on these considerations, we strongly argue for the inclusion of the BPD construct in CCMD-4, perhaps by following the ICD-10 EUPD construct, with its IPD and BPD subtypes.
Future research on BPD in China should focus on the following directions: (1) the epidemiological investigation of EUPD should be conducted in Chinese mainland; noteworthy is the studies focused on the difference between BPD and IPD in Chinese psychiatric patients; (2) the cross-cultural comparison studies on the construct of BPD should also be facilitated; (3) Chinese women have higher suicide rate than man, and especially the impulsive suicidal behavior was common among young rural females.45 Considering the suicide rate among BPD patients is fifty times higher than normal group,4 the relationship between BPD and higher suicide rate in young rural woman should also be investigated.
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