Interference With Wound Healing

Abstract

To the Editor: Individuals with borderline personality disorder (BPD) are characterized by their persistent engagement in various self-destructive behaviors. While common self-destructive behaviors include self-mutilation (eg, cutting, hitting, scratching oneself) and suicide attempts, we have found in a number of empirical studies that some patients with BPD also intentionally prevent wounds from healing. In this study, which combines data from several smaller research projects that we have conducted, we compare the prevalence of interference with wound healing among patients with BPD from psychiatric versus nonpsychiatric (ie, internal medicine, bariatric surgery, family medicine, buprenorphine) treatment settings. Method. Participants consisted of 771 females and 269 males (N = 1,040), both from psychiatric settings (all from 1 inpatient site, n = 441)1–4 and from various medical settings (ie, internal medicine, all from the same site (references 5–9 and R.A.S.; L. Gebauer, MD; T. Moussa, MD; et al, unpublished manuscript, 2007), n = 332; bariatric medicine, from 1 site,10 n = 121; family medicine, from 1 site, n = 3411; buprenorphine treatment, from 1 site,12 n = 112), who participated in 1 of 13 separate research projects. The descriptions of these individual samples can be found in the original reports for each (references 1–12 and R.A.S.; L. Gebauer, MD; T. Moussa, MD; et al, unpublished manuscript, 2007). In all of these individual studies, participants completed 1 of 2 versions of the borderline personality scale of the Personality Diagnostic Questionnaire (PDQ), either the PDQ-R13 or the PDQ-4,14 as well as the Self-Harm Inventory (SHI).15 We used the borderline personality scale of each PDQ version to diagnose borderline personality symptomatology (BPS) in participants. The borderline personality scale of the PDQ is a true/false self-report measure that consists of the diagnostic criteria for borderline personality that are listed in the DSM (ie, PDQ-R, DSM-III-R; PDQ-4, DSM-IV). Various versions of the PDQ have been confirmed as useful screening tools for borderline personality in both clinical16,17 and nonclinical samples,18 including the use of the free-standing borderline scale.19 After dividing the subsamples according to BPS status, we examined participants' responses to 1 item on the SHI, which is a 22-item self-report measure of self-harm behavior—“Have you ever intentionally, or on purpose…prevented wounds from healing?” Results. In the psychiatric samples (n = 441),1–4 325 respondents (73.7%) exceeded the PDQ cut-off score for BPS. Compared to psychiatric respondents who did not exceed the PDQ cut-off score (n = 116), the BPS group was significantly more likely to endorse “prevented wounds from healing” (16.9% vs 9.5%, t1,439 = 2.16, P < .05). In the various medical samples (n = 599),5–13 169 respondents (28.2%) exceeded the PDQ cut-off score for BPS. Compared to respondents who did not exceed the PDQ cut-off score (n = 430), the BPS group was significantly more likely to endorse “prevented wounds from healing” (13.0% vs 1.6%, t1,597 = 4.29, P < .001). In the internal medicine–only samples (n = 332),5–10 78 respondents (23.5%) exceeded the PDQ cut-off score for BPS. Compared to respondents who did not exceed the PDQ cut-off score (n = 254), the BPS group was significantly more likely to endorse “prevented wounds from healing” (12.8% vs 2.0%, t1,330 = 2.78, P < .01). We next considered only those respondents who exceeded the PDQ cut-off score for BPS. Such respondents from psychiatric samples were no more likely to have endorsed “prevented wounds from healing” (16.9%) when compared to respondents from either various medical samples (13.0%, t1,492 = 1.17, P < .15) or internal medicine–only samples (12.8%, t1,401 = 0.95, P < .20). These data indicate several important findings. First, among patients with BPS, whether in psychiatric or medical settings, a similar proportion report preventing wounds from healing (13%–17%). In other words, the prevention of wound healing does not appear to be more common in medical settings. Second, in a psychiatric setting, preventing wounds from healing does not appear to be particularly specific to BPS. Indeed, there may be patients with other types of psychiatric disorders that wash out the specificity of this relationship (eg, obsessive-compulsive disorder, schizophrenia, other personality disorders). In contrast, in a medical setting, the relationship between preventing wounds from healing and BPS is far more specific. Therefore, this behavior in a primary care setting is highly likely to be associated with BPS. This study has a number of potential limitations, including the self-report nature of all data, the use of 2 versions of the PDQ, various nonpsychiatric samples, and the consolidation of multiple samples for analysis. However, it is the only study that we are aware of that has examined in broad psychiatric and medical samples the relationship between BPS and the prevention of wound healing.