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Are inmates’ subjective sleep problems associated with
borderline personality, psychopathy, and antisocial personality
independent of depression and substance dependence?
Laura Harty*, Rebecca Duckworth, Aaron Thompson, Jeffrey Stuewig, and June P. Tangney
Department of Psychology, George Mason University, Fairfax, USA
Abstract
Previous research investigating the relationship between Borderline Personality Disorder (BPD) and
sleep problems, independent of depression, has been conducted on small atypical samples with mixed
results. This study extends the literature by utilizing a much larger sample and by statistically
controlling for depression and substance dependence. Subjective reports of sleep problems were
obtained from 513 jail inmates (70% male) incarcerated on felony charges. Symptoms of BPD were
significantly associated with sleep problems even when controlling for depression. Thus, sleep
problems associated with BPD cannot be attributed simply to co-morbid symptoms of depression
and substance dependence was ruled out as proximal causes for this relationship. Symptoms of
depression, but not Antisocial Personality features, were related to sleep problems independent of
substance dependence. Treatment of individuals with BPD may be more effective if sleep problems
are explicitly addressed in the treatment plan.
Keywords
sleep problems; depression; substance abuse; psychopathy; borderline; personality; anti-social
personality
Borderline Personality Disorder (BPD) is characterized by marked impulsivity and pervasive
instability of affect, self-image, and interpersonal relationships. High rates of substance abuse
(Hatzitaskos, Soldatos, Kokkevi, & Stefanis, 1999; McCann & Ball, 2000), antisocial activity
(Coid, 1993), and behaviors aimed at harming the self (Wilkins & Coid, 1991) or others
(Hernandez-Avila, Burleson, Poling, Tennen, Rounsaville, & Kranzler, 2000) have been
associated with BPD. As a consequence, individuals with BPD are at elevated risk for
involvement in the criminal justice system. Whereas prevalence rates for BPD in the
community are 1–2% (Kraus & Reynolds, 2001), rates among both male and female
incarcerated offenders have been estimated at 23–30% (Jordan, Schlenger, William, Fairbank
& Caddell, 1996; Drapalski, Youman, Stuewig, & Tangney, 2008). In this report, we draw on
data from a larger longitudinal study of jail inmates to examine the implications of BPD for
sleep disturbance, independent of potentially confounding factors such as depression and
substance use. We also extend this literature by considering two other personality disorders
prevalent among inmates – antisocial personality disorder and psychopathy.
*Corresponding author. lhartygmu@gmail.com.
NIH Public Access
Author Manuscript
J Forens Psychiatry Psychol. Author manuscript; available in PMC 2011 February 1.
Published in final edited form as:
J Forens Psychiatry Psychol. 2010 February 1; 21(1): 23–39. doi:10.1080/14789940903194095.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Previous Efforts to Disentangle the relationship of BPD and Sleep Problems,
Independent of Depression
There is a well-documented relationship between symptoms of depression and sleep problems
(Mayers & Baldwin, 2006; Rotenberg, Indursky, Kayumov, Sirota, & Melamed, 2000). In
addition, recent research underscores a link between Borderline Personality Disorder (BPD)
and impairment in sleep (Asaad, Okasha, & Okasha, 2002; Maunchnik, Schmahl, & Bohus,
2005). Since symptoms of depression often co-occur with BPD (Southwick, Yehuda, & Giller,
1995; Westin et al., 1992), recent research has examined whether impairments in sleep quality
in patients with BPD can be largely explained by co-morbid depressive symptoms (Asaad et
al., 2002; Battaglia, Strambi, Bertella, Bajo, & Bellodi, 1999; Bell, Lycaki, Jones, Kelwala, &
Sitaram, 1983; Benson, King, Gordon, & Silva, 1990; De la Fuente et al., 2004).
In an attempt to disentangle the effects between symptoms of depression and symptoms of
Borderline Personality Disorder (BPD), several researchers have assessed sleep quality in small
samples of patients diagnosed with BPD who report no symptoms of depression. Battaglia et
al. (1999) observed sleep anomalies in this subgroup of patients (n = 10, 6 women) compared
to healthy, age- and gender-matched controls (n = 10, 6 women). The results revealed that
persons in the non-depressed BPD subgroup had higher levels of REM density (eye movements
per REM period) during the first REM period than did never-depressed, matched controls, but
did not differ in terms of their delta sleep percentages. Philipsen et al. (2005) did not replicate
Battaglia’s finding for REM density. In their study comparing BPD individuals without current
depression (n = 20, all women) with healthy age- and gender-matched controls (n = 20) across
a broad array of objective measures of sleep, no differences were observed except that those
with BPD had less percentage of Stage 2 sleep relative to controls (Philipsen et al., 2005).
Group differences were more pronounced when considering subjective reports of sleep quality.
While in the sleep lab, patients in the BPD group rated themselves as having more sleep related
problems on a number of indicators, including lower sleep quality, than did controls.
Furthermore, in the two weeks prior to being in the lab, patients in the BPD group rated the
efficiency of their sleep (ratio of sleep time to the amount of time in bed) significantly worse
and were significantly poorer at estimating their total sleep time than were the controls.
Asaad et al. (2002) compared objective and subjective measures of sleep quality obtained from
(a) individuals diagnosed as BPD without co-morbid depressive symptoms (n = 20, 12 women),
(b) individuals diagnosed with depressive symptoms without co-morbid BPD (n = 20, 12
women), and (c) healthy, age- and gender-matched controls (n = 20, 12 women). All of the
depression-only group and 45% of the BPD-only group reported significant sleep problems
whereas only 10% of the control participants indicated subjective sleep difficulties. The
researchers also utilized polysomnography equipment to identify where the three groups
differed. Participants with depression only showed significantly more impaired sleep latency
(between when the participant attempts to sleep and when sleep actually occurs), sleep
efficiency and number of arousals than the BPD only and control groups. Sleep latency and
sleep efficiency were also significantly worse in the BPD group compared to the controls but
there was not a significant difference for the number of arousals (Asaad et al., 2002).
Benson et al. (1990) obtained objective measures of sleep from (a) individuals diagnosed with
BPD and a past or present diagnosis of Major Depressive Disorder (MDD) or Bipolar Disorder
(BD; n = 8, all men), (b) individuals diagnosed with BPD without past/present MDD or BD
diagnosis (n = 10, all men), and (c) age and gender matched healthy controls (n = 15, all men).
In contrast to Asaad et al. no differences were found between BPD groups and controls in sleep
latency (Benson et al., 1990). Compared to controls, both BPD groups had less total sleep,
more Stage 1 sleep, and less Stage 4 sleep. Differences in sleep between the two BPD groups,
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however, were not tested. T-tests were thus applied by the present researchers on the data
presented in their article and significant results were not found.
De la Fuente, Bobes, Vizuete, and Mendlewicz (2001) found differences between sleeping
patterns of (a) BPD patients without current depression (n=20, 14 women), (b) non-BPD MDD
patients (n=20, 15 women), and (c) controls (n=20, 14 women) matched on age and gender.
In contrast to Philipsen et al’s generally null findings, De la Fuente et al. found a number of
different objective measures to be significant between BPD and controls. BPD and MDD
groups had less total sleep, longer sleep latency, and more wakefulness than control subjects.
However, BPD patient sleep was characterized by more REM sleep and less Stage 3, Stage 4,
and slow wave sleep as compared to those with MDD and controls (De la Fuente et al.,
2001). Furthermore when subdividing the BPD group, BPD patients with a past history of
MDD (n=9) reported more wakefulness and less slow wave sleep than BPD patients without
such history (n=11). The authors concluded that while participants with BPD and MDD had
similar sleep-continuity, the groups can be distinguished by the architecture of sleep.
De la Fuente et al. (2004) extended this work by adding a group of patients with Recurrent
Brief Depression (RBD; n = 20, 14 women) to the samples compared in De la Fuente, et al.
(2001). BPD patients had greater REM duration and less stage 3 and slow wave sleep than
RBD patients (De la Fuente et al., 2004).
Finally, Bell et al. (1983) compared patients with BPD and MDD (n=15, 10 women) to patients
with MDD but no current or past Borderline features (n=18, 10 women) on sleep quality and
duration, including percent Delta and percent REM sleep. No differences were observed
between the two groups. However, when depressive symptoms were partialled out, one of the
13 dependent variables (REM latency), was statistically significant. BPD-MDD patients
showed shorter REM latency compared to MDD-only patients (Bell et al., 1983).
Taken together, the available evidence suggests that some – but by no means all – of the sleep
difficulties associated with BPD can be explained by comorbid symptoms of depression.
Available research, however, is limited by a reliance on atypical, discrete groups (e.g., “non-
affective” BPD), small sample sizes, or both. A diagnosis of BPD without a history of
depression is unusual, and thus it is not clear whether the results of studies focusing on “non-
affective” BPD groups generalize to the much larger population of individuals with BPD and
co-morbid affective symptoms.
The Current Study
To better assess the degree to which symptoms of BPD are related to sleep difficulties,
independent of affective symptoms, the current study draws on a much larger sample of
individuals in which symptoms of BPD, anxiety and depression were assessed along
continuous dimensions. As such, the study design provides a much more powerful context in
which to evaluate the question: Is the association between sleep problems and symptoms of
BPD largely accounted for by co-occurring symptoms of depression and anxiety? Or is BPD
independently associated with sleep problems, perhaps reflective of more fundamental self-
regulatory difficulties?
If features of Borderline Personality Disorder are related to sleep problems, independent of
depression and anxiety, an alternative explanation remains. Comorbid substance dependence
may account for the sleep problems reported by patients with BPD. Substance abuse and
dependence are common problems among people with BPD (Miller, Abrams, Dulit, & Fyer,
1993; Trull, Sher, Minks-Brown, Durbin, & Burr, 2000) and sleep problems are also linked to
alcohol and drug dependence (Karam-Hage, 2004; Teplin, Raz, & Daiter, 2006). Thus, in the
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current study, we also examine the degree to which the relationship of symptoms of Borderline
Personality Disorder and sleep problems is independent of symptoms of substance abuse.
Finally, we explore the relation of sleep problems to symptoms of two other disorders of
personality – Antisocial Personality Disorder (ASPD) and psychopathy. The research reviewed
thus far has focused on BPD and sleep in clinical and community samples. However, BPD and
substance abuse may frequently co-occur with ASPD and psychopathy. Thus, studies of
correctional samples are especially important to consider. Lindberg et al., (2003) found that
inmates diagnosed with ASPD who had a history of recurrent violent acts with no history of
psychosis, dementia, or major depression (n = 19, all men) also showed disordered sleep
patterns as indicated by objective sleep parameters, relative to controls (n=11, all men).
Philipsen et al. (2005) noted objective measures of sleep disturbance found in their study of
non-depressed, non-incarcerated female BPD participants were similar to that observed the
sample of incarcerated male participants with ASPD in the Lindberg et al. (2003) study.
Psychopathy is a more serious personality disorder than ASPD, characterized by pervasive
antisocial behavior, as well as marked dysfunction in emotional connectedness to others.
(Antisocial Personality Disorder requires just the former, not the latter.) We were able to locate
only one study which investigated the relationship between sleep and psychopathy. Salley et
al. found no evidence of sleep problems associated with psychopathy in prison sample (n=23,
all males, however, the projective method (Rorschach) used to assess psychopathy is of highly
questionable validity (Salley, Khanna, Byrum, & Hutt, 1980). Further research is needed using
a well-validated measure of psychopathy such as the PCL-R (Hare, 1991). Because substance
abuse is common among individuals diagnosed with Antisocial Personality Disorder and
psychopathy (Hemphill, Hart, & Hare, 1994) we also examined whether any observed
relationships between sleep problems and ASPD and psychopathy are independent of substance
dependence.
Where’s the Diagnosis? DSM-IV-TR and the PAI-BOR Scale
The current study assessed borderline personality using the Personality Assessment Inventory
(PAI, Morey, 1991). Research demonstrates that scores on the PAI-BOR scale converge with
clinicians’ diagnoses of borderline personality disorder based on DSM-IV-TR (APA, 2000)
criteria. In a sample of 63 outpatients (BPD base rate .72), a T-score of 65 was deemed optimal,
with .91 sensitivity, .79 specificity, .94 positive predictive power, .73 negative predictive
power, and an overall correct classification rate of .89 vis-à-vis SCID-II diagnoses (Jacobo,
Blais, Baity, and Harley, 2007). Importantly, the concordance between PAI-derived and
clinician-derived classification is equivalent to the concordance between clinicians using DSM
criteria. For example, in a recent study (Critchfield, Levy & Clarkin, 2007), trained clinicians
using the SCID-II agreed 87% of the time on a diagnosis of BPD (base rate .76). Thus, a cut-
score of 65 on PAI-BOR agrees with a clinician-derived SCID-II diagnosis as well as two
independent SCID-II assessments agree with each other.
Although it is possible to dichotomize the PAI-BOR scale into a meaningful diagnostic
variable, several factors argue against doing so. First, the high cost of dichotomizing continuous
variables in terms of statistical power is well known (Cohen, 1983). Second and related, a
dimensional approach allows for less error in estimating the true shared (and unshared) variance
in syndromes of interest, as is the focus here. Third, as discussed by Krueger and Piasecki
(2002), a correlational approach may be ultimately more useful for assessing co-morbidity
because it circumvents the problem of concordance by chance, especially in cases where the
base rates are quite high, as in the current situation. Fourth, there is ample psychometric
evidence that symptoms of borderline personality are meaningfully distributed on a continuum
(Morey, 1991; Clark, 1999); there exists no empirical evidence arguing in favor of an
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underlying taxon. Thus, for the purposes of the current study we elected not to dichotomize
the PAI-BOR scale, but rather to capitalize on the more complete information inherent in the
continuous measure.
Clinical Relevance of Subjective Experience of Sleep Problems
The current study focused on subjective or felt distress associated with sleep problems. It is
well known that, in many domains of medicine, patients’ subjective experiences do not map
on to physiological realities in a one-to-one fashion. Subjectively experienced pain is only
moderately correlated with objective indicators of injury or pathology. When considering
patients’ functional adaptation to the demands of daily life, it is often the subjective experience,
not the objective physical reality, that is most predictive of key outcomes. For example, in the
domain of social support, subjective perceptions are most consistently and substantially linked
to psychological and social adjustment. Objectively assessed dimensions of social support
account for very little variance (Lakey, 2007). To date, most studies of sleep and BPD have
focused on objective indicators of sleep in atypical patient samples, occasionally including
subjective measures of sleep as a secondary consideration. However, if the focus is on
identifying new targets for intervention in areas causing distress to those with BPD, subjective
measures are of special relevance.
Methods
Participants
Study participants were 513 pre- and post-trial inmates in a metropolitan area county jail. The
targeted population was inmates who would serve at least 4 months in jail. Selection criteria
were (1) either (a) sentenced to a term of 4 months or more, or (b) arrested and held on at least
one felony charge other than probation violation, with no bond or greater than $7,000 bond,
(2) assigned to the jail’s medium and maximum security “general population” (e.g., not in
solitary confinement, not in a separate forensics unit for actively psychotic inmates), and (3)
sufficient language proficiency to complete study protocols in English or Spanish. Of the 603
participants who agreed to participate, 85% (N=513) remained at the jail long enough to
complete portions of the 4–6-session initial assessment relevant to the behaviors reported here.
Participants were on average 32 years old (SD = 10), mostly men (70%), and diverse in terms
of racial/ethnic composition: 35.9% Caucasian, 45% African American, 9% Latina/o, 2.9%
Asian, 0.8% Middle Eastern, 0.4% Native American, and 6% “Other” or “Mixed.”
Procedures
Shortly after their move to the jail’s “general population” (about 1–2 weeks), eligible inmates
were presented with a description of the study and asked to participate. It was emphasized that
the decision to participate or not would have no bearing on their status at the jail or their release
date. Interviews were conducted in the privacy of professional visiting rooms and the data are
protected by a Certificate of Confidentiality from Department of Health and Human Services.
Inmates who completed the 4–6 session intake assessment received a $15–18 honorarium, an
amount deemed non-coercive based on interviews with knowledgeable informants (i.e.,
inmates and deputies) familiar with the economy of this particular correctional setting.
Participants with sufficient English skills completed questionnaires using “touch-screen”
computers that presented items visually and aurally. For participants requiring Spanish versions
of the measures (less than 5% of male participants), questionnaire responses were gathered via
individual interview. Both the interviewer and participant had paper copies of the translated
measures; however to approximate the level of privacy afforded by the touch-screens,
participants filled in their own responses.
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Measures
Borderline Personality, Antisocial Personality, Depression, and portions of a Sleep Problems
Index were assessed with the Personality Assessment Inventory (PAI) (Morey, 1991) a 344
item self-report measure of clinically relevant psychopathology and personality traits. The PAI
includes 13 clinical syndrome scales, many of which include subscales reflecting the
multidimensional structure of most psychological disorders. In the current study, internal
consistency estimates of reliability were acceptable, and consistent with those reported by
Morey (Morey, 1991).
Borderline Personality—The Borderline Features total scale of the PAI comprises four
subscales each comprised of six items: Affective Instability, assessing the intense and largely
unmodulated emotional experiences with an emphasis on anger; Identity Problems, assessing
confusion about self-identity and lack of an integrated concept of self and others; Negative
Relationships, reflecting ambivalence about interpersonal relationships, characterized by acute
dependence, fear of abandonment, and distrust; and Self-Harm, ostensibly reflecting self-
harming behaviors that are characteristic of individuals with BPD, however most items assess
the more general characteristic of impulsivity also a hallmark of BPD. Internal reliability of
the total Borderline scale was high (α = .89) while the subscales were acceptable (α = 64 to .
77; mean α = .73). Overall, 31% of the sample obtained T-scores of 70 or above on the total
Borderline scale, the cut score deemed as clinically significant by Morey (1991); 45.5%
obtained T-scores of 65 or above, the cut score identified as optimal by Jacobo, et al, (2007).
Antisocial Personality—The Antisocial Features scale (ANT) (α = .85) of the PAI includes
the subscales of Antisocial Behaviors, Egocentricity, and Stimulus-Seeking. Each subscale
contained eight items and the internal reliability of the subscales were acceptable (α = .70, .
66, .74).
Depression—Three depression subscales from the PAI were used as control variables for
the analyses. The first measures cognitive aspects (8 items, α = .77); the second measures
affective features of depression (8 items, α = .79); and the third taps physiological symptoms
of depression. For the purposes of this study, we considered here only items that do not refer
to sleep problems (4 items, α = .56).
The Psychopathy Checklist-Screening Version—(PCL:SV) (Hart, Cox, & Hare,
1995) is a clinical rating instrument used to assess psychopathy. Like the PCL-R (Hare,
1991), the PCL:SV provides a total psychopathy score as well as two factor scores. Factor 1
captures the personality characteristics associated with psychopathy, including superficiality,
grandiosity, deceitfulness, lack of remorse, lack of empathy, and lack of responsibility. Factor
2 captures the behaviors associated with psychopathy, such as impulsivity, poor behavioral
controls, lack of goals, irresponsibility, adolescent antisocial behavior, and adult antisocial
behavior. Single measure intraclass correlations, using a one-way random effects model, were .
85, .88, and .87 for Factor 1, Factor 2, and Total PCL:SV scores, respectively, showing a high
degree of interrater reliability.
Drug and alcohol dependence—Drug and alcohol dependency symptoms were assessed
using Simpson and Knight’s (Simpson & Knight, 1998) Texas Christian University
Correctional: Residential Treatment Form, Initial Assessment (TCU-CRTF). Specifically, four
scales were created to assess symptoms of dependency on alcohol, marijuana, cocaine, and
opiates in the year prior to incarceration. Each scale was composed of items that assess each
of the DSM-IV (APA, 2000) substance dependence domains (e.g., for the domain of tolerance
participants answered the question “How often did you find that your usual number of drinks
had much less effect on you or that you had to drink more in order to get the effect you
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wanted?”). For domains with multiple items, responses were averaged and a total score was
computed by taking the mean across the domains (α = .92 to .98).
Sleep Problems—A five-item index of sleep problems was created comprising four items
from the PAI’s physiological subscale of depression that deal explicitly with sleep problems
(I have no trouble falling asleep (reversed), I rarely have trouble sleeping (reversed), I often
wake up very early in the morning and can't get back to sleep, I often wake up in the middle
of the night) and one item from the Cohen-Hoberman Inventory of Physical Symptoms
(CHIPS; Cohen & Hoberman, 1983) (How much were you bothered by sleep problems [for
instance, can't fall asleep, wake up in the middle of night or early in the morning]?). The
individual items were standardized and then averaged. Reliability of the 5 item index was good
(α = .79). Inspection of the items indicates strong face validity and, regarding content validity,
the range of content is very similar to other widely used self report measures of sleep problems.
An exploratory factor analysis extracted one factor verifying that the scale yields a
unidimensional index of subjective sleep problems, similar to the widely used three-and four-
item sleep problem scales developed by Jenkins, Stanton, Niemcryk & Rose (1988). Other,
longer self-report measures of sleep problems exist, but with few exceptions the researchers
in the field focus on subjectively experienced sleep problems as a unidimensional construct.
Results
Pearson’s bivariate correlations were conducted to determine the extent to which subjective
sleep problems were associated with symptoms of BPD, antisocial personality disorder,
psychopathy, depression, and substance dependence (See Table 1). Consistent with previous
studies there was a significant positive correlation between sleep problems and BPD.
Furthermore, all four BPD subscales -- Affective Instability, Identity Problems, Negative
Relationships, and Self Harm (assessing primarily impulsivity) -- were related to sleep
problems. Positive correlations were also found between sleep problems and antisocial and
stimulus seeking features of antisocial personality, Factor 2 psychopathy, cognitive, affective,
and (minus sleep problem items) physiological depression, and symptoms of alcohol, cocaine
and opiate dependence specifically (see Table 1).
When indices of cognitive, affective, and physiological depression (not including sleep items)
were partialled out, the correlation between BPD and sleep problems remained significant.
Symptoms of BPD were associated with poor sleep, above and beyond the influence of any
co-morbid depressive symptoms. In contrast, the association between sleep problems and most
other personality and behavioral problems (antisocial behavior, sensation-seeking,
psychopathy, alcohol and cocaine dependence) did not hold once depression was partialled
out. Only opiate dependence showed a unique relationship to sleep problems, beyond
depression.
Next, we examined the degree to which the association between sleep problems and personality
and behavioral problems could be attributed to co-morbid substance dependence. The right-
most column of Table 1 presents the relationship of psychological measures to sleep problems,
partialling out alcohol, marijuana, cocaine, and opiate dependence. When controlling for
substance dependence, sleep problems remained significantly associated with BPD and
depression. The link between sleep problems and features of antisocial personality and Factor
2 psychopathy appears largely due to substance dependence, depression, or both.
Discussion
In the present study of 513 jail inmates, BPD and its four subscales (identity problems, negative
relationships, self-harm and affective instability) were significantly associated with the
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subjective experience of sleep problems. Further, the relationship between subjective sleep
problems and the BPD total scale as well as the subscales remained significant when controlling
for co-morbid depression, assessed in detail along three sub-dimensions (affective, cognitive,
and physiological). These results indicate that symptoms of BPD are uniquely associated with
sleep problems above and beyond the effect of depression, which itself is associated with sleep
difficulties. In short, the sleep problems associated with BPD cannot be attributed simply to
co-morbid symptoms of depression.
The current results also speak to the question of whether subjective sleep problems experienced
by individuals with BPD may be due to co-morbid substance dependence. Although substance
use is common among individuals with BPD (Miller et al., 1993; Trull et al., 2000) and also
can exacerbate sleep problems, to our knowledge no previous studies have taken into account
chronic substance use or dependence when examining the link between BPD and sleep
problems.1 In the current study, a detailed assessment of participants’ recent history of
substance use and symptoms of dependency was conducted. Analyses indicated that the link
between BPD and sleep problems was independent of the effects of substance dependence.
Sleep problems appear to be uniquely related to symptoms of BPD.
In contrast, although sleep problems were associated with features of antisocial personality,
Factor 2 psychopathy (antisocial lifestyle), and alcohol, and cocaine dependence at the bivariate
level, these findings did not remain significant when depression was partialled out. In other
words, depression accounted for these correlations, suggesting that co-morbid symptoms of
depression were primarily responsible for the sleep problems associated with these personality
and behavioral factors. Only the relationship between opiate dependence and sleep problems
remained significant after controlling for depression. Opiate dependence appears to have a
unique relationship with sleep problems above and beyond the effects of depression.
Previous research investigating the relationship between BPD and sleep problems, independent
of depression, have been conducted on small, atypical samples of individuals with BPD (e.g.,
patients with BPD but with no history of depression) and have yielded mixed results. The low
statistical power of previous studies precludes interpretation of null findings, and the use of
atypical patient samples seriously limits the ability to generalize results to the larger BPD
population. The present study circumvented limitations of the previous research by obtaining
data from a much larger sample and by statistically controlling for the effects of depression,
rather than attempting to segregate the sample into discrete clinical groups. In addition, this
study extends the empirical research on sleep problems associated with BPD by ruling out
substance dependence as a proximal cause for this relationship.
Clinical Implications
People with BPD are particularly vulnerable to sleep difficulties, above and beyond what would
be expected due to co-occurring depression (or substance abuse problems). Thus, mental health
professionals working with individuals with BPD should routinely assess the degree to which
such clients are experiencing difficulties with sleep. Given that sleep problems have been found
to significantly increase the risk for aggression (Ireland & Culpin, 2006), depression (Kupfer,
2006; Perlis et al., 2006; Perlman, Johnson, & Mellman, 2006; Roman, Hagewoud, Luiten, &
Meerlo, 2006) and other psychiatric illnesses (Hajak et al., 2003) treatment of individuals with
BPD may be more effective if sleep problems are explicitly addressed in the treatment plan.
There are a range of effective behavioral and psychopharmacological interventions for
ameliorating this source of stress and distress.
1De la Fuente, et al.’s (2001, 2004) study included a “drug washout period,” but individual differences in substance abuse were not
considered.
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In addition, these results may provide clues for basic research on the biopsychosocial bases of
BPD. Although sleep problems are associated with a range of psychological problems, most
can be explained by co-morbid symptoms of depression. BPD stands out as having a special,
independent link with sleep problems. It is possible that the problems with sleep regulation
experienced by individuals with BPD are reflective of a more general impairment in self-
regulation. A common biological substrate may account for both BPD-related sleep problems
and for the severe impairment in psychological self-regulation that is the hallmark of BPD.
Limitations and Directions for Future Research
Although the current study adds substantially to the literature on sleep problems among
individuals with BPD, the research is not without limitations. First, this study relied on self-
reports for many of the measures. Nonetheless, research suggests that the Personality
Assessment Inventory has a high concordance with clinical diagnoses (Jacobo, et al., 2007).
And although research has documented a clear relationship between subjective and objective
measures of sleep (Carlson, Karlson, Hamilton, Nelson, & Luxton, 2006) the two types of
measures are by no means synonymous. Moreover, Philipsen et al. (2005) found that
discrepancies between subjective and objective measures of sleep quality were, if anything,
more pronounced among individuals with BPD, relative to asymptomatic controls. Future
research, employing polysomnography recordings would provide a more detailed picture of
the physiological patterns associated with perceived sleep problems as experienced by
individuals with BPD.
Second, the current study used a dimensional measure of borderline personality disorder; thus
it was not possible to examine definitive diagnoses at the individual level. Although
dimensional assessments are most consistent with the actual distribution of patient
characteristics and offer greater statistical precision than diagnostic dichotomies, future work
also employing clinician-rated diagnostic measures would be useful.
Third, borderline personality disorder is often comorbid with other mental health problems that
may influence sleep disturbances. While data on the symptoms of depression and substance
dependence were gathered in this study, symptoms of other disorders that influence sleep
problems such as attention-deficit/ hyperactivity disorder and post-traumatic stress disorder
were not collected. This would be a useful direction for future research.
Finally, additional research is necessary to determine whether these findings apply to
individuals in noncorrectional settings. The sample used in the current study was drawn from
a jail inmate population, rather than a more traditional clinical setting. It’s worth noting,
however, that jail inmates do not represent a particularly atypical subgroup of individuals with
BPD. Deinstitutionalization of the mentally ill has led to a dramatic increase in incarceration
rates over the past few decades. In the current study, 77% of participants scored in the clinical
range on at least one of the PAI clinical scales (Drapalski, et al., 2008), a figure consistent with
other studies employing clinician-based diagnostic assessments (Teplin, Abram, &
McClelland, 1996; Teplin et al., 2006). The prevalence of BPD is astoundingly high and gender
neutral in correctional settings (Jordan, Schlenger, Fairbank, & Caddell, 1996; Tangney,
Stuewig, Hastings, & Hashemi, 2004). Thus, jail inmates represent a large, woefully
unrecognized, understudied and underserved subgroup of individuals with BPD. Recognizing
and examining how BPD and sleep problems may co-occur above and beyond other symptoms
of psychopathology may help us gain insight into new ways to intervene and treat this
debilitating disorder.
Harty et al. Page 9
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Table 1
Relationship of sleep problems to personality disorders.
Bivariate
correlations Partial correlations
Cognitive, affective, &
physiological
depression removed
Substance
dependence
removed
Borderline personality – total scale .43** .20** .39**
Affective instability .32** .10*.29**
Identity problems .41** .16** .37**
Negative relationships .36** .19** .32**
Self-harm .30** .14** .24**
Antisocial personality – total scale .14** .00 .06
Antisocial behaviors .15** .05 .06
Egocentricity .08 −.05 .03
Stimulus seeking .13*.00 .06
PCL-SV – Psychopathy total .06 .06 .01
Factor 1 - Psychopathic personality −.02 .03 −.04
Factor 2 – Antisocial lifestyle .12** .07 .06
Cognitive depression .39** --- .36**
Affective depression .42** --- .39**
Physiological depression .42** --- .40**
Alcohol dependence symptoms .14** .04 ---
Marijuana dependence symptoms .07 .00 ---
Cocaine dependence symptoms .11*.05 ---
Opiate dependence symptoms .21** .17** ---
Note: N = 498--512 (N = 467 for psychopathy).
*p<.05;
**p<.01.
J Forens Psychiatry Psychol. Author manuscript; available in PMC 2011 February 1.
