Approximately 1 in 5 adults in the United States, or about 46.6 million people in 2017, live with a mental illness,1 which by definition can be any psychiatric condition with varying degrees of severity ranging from mild to moderate to severe. The term serious mental illness (SMI) refers to a small but severe subset of any mental illness (AMI).1
Definition of Serious Mental Illness
In the 1992 Alcohol, Drug Abuse and Mental Health Services Administration Reorganization Act (Public Law 102-321),2 Congress directed the Secretary of Health and Human Services to develop a federal definition of SMI to aid in the estimation of SMI incidence and prevalence rates in states that were applying for grant funds to support mental health services. The Act led to the creation of the Substance Abuse and Mental Health Services Administration (SAMHSA). According to the Center of Mental Health and Services, which was established within SAMHSA (a part of the National Institute of Mental Health), an adult with an SMI is defined as a person who is “(a) age 18 and older, (b) who currently or at any time during the past year, (c) have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental Disorders, (d) that has resulted in functional impairment which substantially interferes with or limits one or more major life activities…All of these disorders have episodic, recurrent, or persistent features; however, they vary in terms of severity and disabling effects.”3,4
According to the US Equal Employment Opportunity Commission (EEOC), the Americans with Disabilities Act (ADA) defines mental impairment as “any mental or psychological disorder such as major depression, bipolar disorder, anxiety disorders (which include panic disorder, obsessive compulsive disorder, and post traumatic stress disorder), schizophrenia, and personality disorders.” EEOC's enforcement guidelines on the ADA further stipulate that the impairment must “substantially limit one or more major life activities of the individual.” Major life activities may include work, sleep, self-care, thinking, concentrating, learning, and other day-to-day activities.
In 2017, there were an estimated 46.6 million adults age 18 years or older (18.9% of all US adults) with AMI, with the prevalence being higher in women (22.3%) than men (15.1%).1 According to the 2017 National Survey of Drug Use and Health by SAMHSA, approximately 11.2 million US adults age 18 years or older (about 4.5% of the adult population) had been diagnosed with an SMI, with the prevalence being higher in women (5.7%) than men (3.3%).1 Young adults age 18 to 25 years had the highest prevalence of SMI (7.5%), followed by those age 26 to 49 years (5.6%), and then those older than age 50 years (2.7%).1
Admittedly, the federal definition of SMI is a broad one; however, schizophrenia, bipolar disorder, and major depressive disorder typically come up in the discussion of SMIs, whereas other illnesses such as posttraumatic stress disorder, eating disorders, or personality disorders are less commonly discussed. To this end, the National Institute of Mental Health supports the notion that all mental illnesses could potentially cause functional impairment and, therefore meet the meaning of “serious” defined by the federal agency4 when certain severity thresholds are met or exceeded.
In 2016, the 21st Century Cures Act was passed into law, establishing the Interdepartmental Serious Mental Illness Coordinating Committee to address the needs of adults with SMI and the needs of children and youth with serious emotional disturbance (SED).5 The Act helps this vulnerable population have access to adequate care and decreases the risk of incarceration homelessness, suicide, and homicides.6 The initial report from the committee, published in 2017, set the groundwork for areas of focus and future directions that included the following: (1) strengthen federal coordination to improve care, (2) better access and engagement, (3) greater availability of evidence-based treatment and recovery support services, (4) increase opportunities for jail diversion and improve care for people with SMI and SED involved in the criminal and juvenile justice systems, and (5) develop finance strategies to increase availability and affordability of care.5
The operationalization and implementation of SMI were left to be determined by individual state mental health agencies using public and private funds alongside federal grants.3 Although this allows for individual states or local governments to allocate resources based on local needs and priorities, it specifies that the above criteria must be met for those people whose services are funded through the Federal Community Mental Health Service block grant.3
Although many states reflect the same Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)7 categories in their definition, the legal definitions of SMI used in the criminal justice system varies widely across states. For example, New Jersey describes SMI as a “mental health problem” that warrants admission to a mental health unit, whereas Alabama refers to it as a “syndrome,” and the state of Delaware does not appear to have a legal definition at all.8
Why BPD Should be Widely Considered an SMI if Using the us Definitions
BPD is among the most common problems seen in psychiatric practice, affecting up to 1 in 5 psychiatric outpatients.9 Although the condition usually emerges between puberty and young adulthood, diagnosis and treatment is often delayed until late in the course of the illness, leading to more significant functional impairment and limiting treatment efficacy.10
BPD is now understood to be a unitary construct across the lifespan with a rise in pathology in the pubertal period that subsequently wanes from early adulthood onwards, partly due to maturation and socialization.11 Furthermore, it is now known that disruptive behavior, attention disturbances, and emotional dysregulation in childhood conditions such as attention-deficit/hyperactivity disorder, oppositional defiant disorder, substance use disorder, self-injury, anxiety, and depression can all be precursors to an emerging diagnosis of BPD.12
Beginning with childhood and early adolescence, patients with current or emerging BPD present many distressing symptoms that fit the criteria of SMI. These include frequent and persistent depression (with suicidal ideation and attempts), stressful peer interactions, intense negative affect and aggression (especially in girls), and auditory hallucinations that are indistinguishable from patients with schizophrenia.13 Also, like most patients with SMI, young people with personality disorders such as BPD have substantially increased mortality over their lifespans, with reduced life expectancy (17.7 years for men and 18.7 years for women) from multiple causes including suicide, homicide, substance use, and reduced physical health.12 In young people, BPD has also been associated with poor general health, including cardiovascular conditions at a young age, arthritis, and gastrointestinal conditions. Also, about 55% of patients with BPD are nicotine dependent by age 16 years.12
Psychiatric morbidity in patients with BPD persists into adulthood, with depressive disorders occurring in up to 80% of patients and a lifetime prevalence of dysthymia between 12% and 39%.14 In addition, psychotic symptoms, which frequently occur in patients with BPD, are associated with a high incidence of suicide attempts.15 Patients with BPD also exhibit impairments in multiple areas including frequent dissociation, executive dysfunction, deficits in social cognition, and deficits in reality testing similar to patients with schizophrenia and psychotic spectrum disorders.16,17
In Europe, there has been a clear consensus in recent years on the importance of devoting more resources and treatment for people with SMI. However, there is no clear and consistent guideline across the continent on what constitutes SMI. Member countries of the European Union themselves have little consistency in how SMI is defined. In some countries, such as Italy, there is no consistent guidance in place to identify and target patients with SMI.18 In the United Kingdom, according to the guidelines of National Health Service, only schizophrenia, bipolar, and other nonorganic psychotic conditions are considered SMI.19 Based on these definitions, BPD does not reach the threshold of SMI. However, in the UK, the definition of SMI with the broadest consensus is that of the National Institute for Mental Health in England, which includes nonorganic psychosis and personality disorder among its criteria.18 Recently, to address the severity of other mental illnesses, the National Health Service has strongly considered providing more health care resources for personality disorders.20
BPD in Real Life: Why Does BPD Develop into a Severe Mental Illness?
Borderline traits, as well as the full-fledged personality disorder, are harbingers of psychosocial morbidity. However, although this is a well-known clinical fact, little is understood about the development of this trajectory.
The social and emotional dysfunction may start early in life. A high rate of childhood maltreatment is found in the history of people with personality disorders in general, and BPD in particular.21 The National Epidemiologic Survey on Alcohol and Related Conditions inquired about emotional, physical, and sexual abuse; physical or emotional neglect; and household dysfunction (witnessing domestic violence or substance use, incarceration or severe mental illness of other people in the household). The results indicate that people with cluster B personality disorders had more than a 50% chance of having been exposed to some sort of household dysfunction, and at least 1 in 3 patients had been sexually abused.21 Of note, these prevalences cover the general population and are lower than prevalences noted in clinical samples. Unsurprisingly, the experience of childhood adversity increased the diagnostic rates of personality disorders in adulthood, although not all children who have been abused develop personality disorders. Youth and young adults with borderline features (between 1 and 4 symptoms [ie, not meeting full diagnostic criteria]) were found to have poorer psychosocial functioning when compared with youth with no borderline features.22 Thus, even subthreshold symptoms can affect social and emotional development and may constitute a precursor of poor functioning.
Emotional instability and intense interpersonal relationships are a hallmark of BPD. Adolescents with borderline symptoms (even without the formal disorder) had earlier and more intense involvement in romantic relationships. A study by Lazarus et al.,23 which observed 2,310 girls, showed that increased borderline symptoms at age 15 years “predicted increases in antagonism, verbal aggression, and physical aggression” as well as higher levels of relational insecurity. Taken in stride with the background of childhood maltreatment, the picture of instability solidifies, as some youth with borderline features do not have safe or constructive family backgrounds to turn to in case of relationship difficulties.
As adolescents afflicted with borderline traits or personality grow into adults, the impact of the illness translates into impairment at work. As an adult the relationship impairment is not necessarily resolved, but the employment challenges present a new layer often not present in adolescence. In surveying more than 3,600 people as part of the Netherlands Mental Health Survey and Incidence Study-2, Jurrlink et al.24 found that the presence and number of borderline symptoms was “consistently associated with impaired work performance” after controlling for working conditions and other mental disorders such as depression. Three types of work impairments were examined using the World Health Organization Disability Assessment Schedule: inability to work, reduction of working hours, and diminished quality at work. Borderline features appear to link to job insecurity, low decision latitude, and low coworker support. Personality disorders represent an independent risk factor for disability pensioning regardless of the presence of other mental illnesses.25
As patients with BPD age, they represent a disproportionate percentage of people with medical conditions, especially high service users. Patients with BPD are high users of mental health services, including outpatient and inpatient resources, compared to patients with other mental illnesses or healthy control groups.26 Although BPD has a prevalence of up to 3.5% of the general population, it represents a subsegment of patients with mental illness who suffer from a range of ailments, including cardiovascular diseases, stroke, metabolic disease including diabetes and obesity, gastrointestinal disease, arthritis and chronic pain, venereal diseases and HIV infection, and a high preponderance of sleep disorders.27 Borderline personality symptoms are consistently related in epidemiological studies to worse physical functioning, role limitations, fatigue, and pain even when controlling for other conditions (such as depressive symptom severity) or the presence of health behaviors (ie, smoking, drinking, exercise).28 People with BPD report higher impairment from pain conditions even when receiving disability.29 Treating patients with BPD with psychotherapy decreased overall medical health expenditures in a 36-month trial comparing intensive outpatient versus outpatient care.30 This suggests that medical resource use is not purely related to medical issues but also to perception of one's issue and the (potentially negative) response this patient subgroup gets from health care providers.
Lastly, patients with BPD experience more loneliness than healthy controls.31 As loneliness worsens, the effects are seen on social network size, social behaviors, and level of engagement. Loneliness is linked to more interpersonal problems and vice versa,32 but loneliness is also a culprit in worsening medical issues and comorbidities in large epidemiological samples regardless of presence of BPD.33 One can imagine that interpersonal deficits experienced by people with BPD can affect their degree of loneliness and thus the social support they have when medical illnesses start or worsen.
Stigma and Counter-Transference
BPD is a complicated condition in which clinicians and patients alike can contribute to the self-perpetuating cycle of the stigma that goes beyond the stigma related to other mental illnesses.34 The pathological interpersonal difficulties with which patients with BPD struggle can affect the relationship between clinician and patient and elicit negative reactions from the clinician, just as these behaviors affect other relationships for the patient. Some clinicians can have significant negative counter-transference toward patients with BPD that results in reduced tolerance of patients' behaviors and decreased emotional connection. As clinicians instinctively or protectively withdraw from people with BPD who demonstrate the very difficulties that are characteristic of the disorder, patients may, in turn, respond to this emotional distance with more heightened feelings of abandonment and sensitivity to rejection and react further with negative behaviors.34
Although sample sizes are typically small with variable methodologies, most studies suggest negative perceptions of and emotional responses toward patients with BPD. The most studied group of mental health providers has been psychiatric nurses.35 A review of 40 studies about responses of mental health nurses to patients with BPD revealed that the nurses' responses could be counter-therapeutic.36 In a survey of 134 practicing psychiatrists in the US, 57% reported at some point not disclosing BPD to their patients, and 37% responded that they had not documented the diagnosis; for this group of respondents, most agreed that either stigma or uncertainty of diagnosis contributed to their decisions.37 These findings highlight the continued need for patient with BPD to receive an early and reliable diagnosis.37
When patients are unaware of their BPD diagnosis, this lack of information can delay engagement and effective treatments. A review of 30 studies that compared the experiences of stigma toward BPD from patient and mental health provider perspectives revealed common themes of stigma, including (1) diagnosis and disclosure, (2) perceived untreatability, (3) patient preconceptions, (4) feeling powerless, (5) low BPD health literacy, and (6) overcoming stigma through enhanced empathy.38 Further psychoeducation for not only patients but also mental health clinicians will be essential to affect earlier and focused treatment of patients with BPD.
In the DSM-5,7 two approaches for diagnosis of personality disorders are presented. The traditional approach, known to clinicians, relies on meeting criteria for a certain duration. The alternative approach classifies symptoms based on five domains: (1) negative affectivity, (2) detachment, (3) antagonism, (4) disinhibition, and (5) psychoticism. So how do those dimensions play out in health care interactions of patients with BPD?
In the everyday interactions with patients suffering from BPD, the alternative approach to diagnosing and assessing BPD might be helpful in understanding why people with BPD may have more difficulty in psychosocial functioning. In modern health care systems, short clinical encounters and fragmented care can contribute to negative affectivity and antagonism being prominent in the encounters without having adequate time to address and overcome these traits or behaviors. Disinhibition, another dimension with which BPD patients may struggle, can invite judgment in health care professionals with low BPD literacy.
Additionally, borderline-like behaviors, including disinhibition, substance use, erratic relationships and nonsuicidal self-harm, may be dismissed as an adolescent phase. Traditionally, diagnosing personality disorders has been frowned upon in adolescents. Recent evidence, however, points to the fact that adolescents meeting criteria for BPD report high impairment and symptoms as severe as those of adults with a diagnosis of BPD.39 In such cases, clinicians should be mindful of counter-transferential feelings that could affect medical decision-making. The physician should ask: can I link this adolescent or young adult to treatment? Is a more intensive treatment needed? And have all the social factors, including potential maltreatment, taken into account?
The watershed area of risk factors for BPD and likelihood of victimization in relationships and in active substance use is not well explored, and several gaps exist in our understanding of psychosocial trajectories of people with personality disorders in general and BPD in particular. The association of BPD with human trafficking is unknown, although the likelihood of unhealthy relationships and domestic violence is well established.40 It is easy to ignore or miss worrisome findings of substance use, intimate partner violence, coercion, and even full-fledged trafficking when the patient is deemed unlikable or manipulative, which is often how many patients with BPD are seen.
The mechanisms by which BPD develops are still not fully understood. However, poly-victimization (not just maltreatment) is a powerful predictor. In an intriguing analysis of more than 700 youths, Kerig and Modrwoski41 prove that the borderline behaviors often labeled problematic by the health and legal system, and sometimes leading to juvenile legal involvement, stem from emotional numbing and dissociation, which can lead to callous or unemotional behavior. Negative counter-transferential feelings can effectively blind clinicians to the dire need of a trauma-informed perspective in this population. If untreated, these symptom clusters can lead to a deleterious life trajectory with significant impairment.
BPD should be considered as an SMI according to the definition from the Center of Mental Health and Services. BPD affects social, interpersonal, and medical trajectories of affected people. Addressing the stigma and counter-transference issue associated with this condition is imperative in early detection and appropriate referral and treatment, which are necessary to improve engagement with the health care system and improve outcomes.
- National Institute of Mental Health. Mental illness. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml. Accessed December 3, 2019.
- Government Publishing Office. Estimation methodology for adults with serious mental illness. Fed Regist. 1999;64(121):33890–33897. https://www.govinfo.gov/content/pkg/FR-1999-06-24/pdf/99-15377.pdf. Accessed June 18, 2019.
- Substance Abuse and Mental Health Services Administration. Final notice. https://www.samhsa.gov/sites/default/files/federal-register-notice-58-96-definitions.pdf. Accessed December 3, 2019.
- National Institute of Mental Health. Post by Former NIMH Director Thomas Insel: Getting serious about mental illnesses. https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/getting-serious-about-mental-illnesses.shtml Accessed December 3, 2019.
- Interdepartmental Serious Mental Illness Coordinating Committee. The way forward: federal action for a system that works for all people living with SMI and SED and their families and caregivers. https://store.samhsa.gov/product/The-Way-Forward-Federal-Action-for-a-System-That-Works-for-All-People-Living-With-SMI-and-SED-and-Their-Families-and-Caregivers-Full-Report/PEP17-ISMICC-RTC. Accessed December 15, 2019.
- Treatment Advocacy Center. Fast facts. https://www.treatmentadvocacycenter.org/evidence-and-research/fast-facts Accessed December 3, 2019.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013:779–781.
- Treatment Advocacy Center. Research weekly: what is “serious mental illness”?. https://www.treatmentadvocacycenter.org/fixing-the-system/features-and-news/3771-research-weekly-what-is-qserious-mental-illnessq. Accessed December 3, 2019.
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- Bateman AW, Gunderson J, Mulder R. Treatment of personality disorder. Lancet. 2015;385(9969):735–743. https://doi.org/10.1016/S0140-6736(14)61394-5 PMID: doi:10.1016/S0140-6736(14)61394-5 [CrossRef]25706219
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- Kelleher I, Ramsay H, DeVylder J. Psychotic experiences and suicide attempt risk in common mental disorders and borderline personality disorder. Acta Psychiatr Scand. 2017;135(3):212–218. https://doi.org/10.1111/acps.12693 PMID: doi:10.1111/acps.12693 [CrossRef]28185269
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