Borderline personality pathology and insomnia symptoms in community-dwelling older adults.

Borderline personality disorder is defined by symptoms such as affective instability, impulsivity and identity disturbance. These, along with other characteristic pathological symptoms such as unstable relationships, intense anger and suicidal behaviour inevitably interfere with various aspects of a person’s life and are associated with an increased risk of medical illnesses (Frankenburg & Zanarini, 2004). The estimated prevalence of BPD is 2.9% in the general population (Trull, Jahng, Tomko, Wood, & Sher, 2010). In addition to the symptoms and consequences described earlier, borderline pathology has been associated with sleep problems (e.g. Asaad, Okasha, & Okasha, 2002; Harty, Forkner, Thompson, Stuewig, & Tangney, 2010; Semiz, Basoglu, Ebrinc, & Cetin, 2008). Sleep problems present a major hardship in their own right and are associated with increased risk for stressful life events, mood disorders and problems with health, family, work and school (Bastien, Vallieres, & Morin, 2004; Harvey, 2011; Healey et al., 1981). Up to the present time, research linking BPD and sleep problems have predominantly explored the relationship in small clinical samples of young adults and largely ignored its development across the lifespan. Prior studies using self-reported sleep quality have demonstrated that sleep problems are the characteristic of younger individuals with borderline pathology (Asaad et al., 2002; Philipsen et al., 2005; Schredl et al., 2012; Semiz et al., 2008). Philipsen et al. (2005) found with a sample of 20 non-depressed BPD patients that, in comparison with controls, BPD patients complained of significantly reduced total sleep quality as well as significantly decreased sleep time, decreased sleep efficiency, feeling significantly more exhausted and a worse evening mood. Self-reported sleep quality was also significantly impaired in a study of 27 non-depressed BPD patients by Schredl et al. (2012). The patients reported significantly more sleep arousals, awakenings, time awake and overall sleep quality problems. Semiz et al. (2008) found that 96% of 88 non-depressed BPD patients self-identified as poor sleepers, as compared with only 12% of controls, and had a significantly higher rate of nightmares and dream anxiety than controls. Asaad et al. (2002) reported that 45%of 20 non-depressed BPD patients complained of sleep problems in comparison with only 10% of controls. Examining a larger sample of 513 jail inmates (70% men), Harty et al. (2010) found borderline pathology to be significantly correlated with sleep problems on the Personality Assessment Inventory (Morey, 1991). These studies all reported mean ages in the 20s (with the exception of Harty et al., who reported a mean age of 32). Taken as a whole, this evidence demonstrates that significant self-reported sleep problems are prevalent in younger adults with borderline personality pathology. Using data from the National Comorbidity Survey Replication (Kessler & Merikangas, 2004), Selby (2013) recently reported that symptoms of BPD were significantly related to sleep disturbance in a community-based sample of 5692 participants aged 18 years and up. Data reported in this paper represent a significant advance beyond earlier studies, but the results were not examined with regard to age, leaving unanswered questions about sleep and symptoms of BPD in older adults. Polysomnography (PSG) has also been used to examine the relationship between BPD and sleep problems in younger adults (Mage in the 20s and 30s). PSG studies have found sleep differences between BPD-only patients (without co-morbid major depression) and controls. For example, Asaad et al. (2002) found that BPD patients without a history of depression have significantly greater sleep onset latency, less sleep efficiency, lower slow wave sleep percentage, higher rapid eye movement (REM) percentage and REM density, shorter REM latency and longer first REM period in comparison with controls. Some of these findings have been replicated, whereas others have not. For example, regarding the finding of shortened REM latency, which is associated with major depression (Giles, Roffwarg, & Rush, 1990), four studies replicated this finding in BPD patients when compared with controls (Akiskal, Yerevanian, Davis, King, & Lemmi, 1985; Battaglia, Ferini-Strambi, Smirne, Bernardeschi, & Bellodi, 1993; McNamara et al., 1984; Schredl et al., 2012). However, four comparable studies did not find shortened REM latency in BPD patients compared with controls (Benson, King, Gordon, & Silva, 1990; De la Fuente, Bobes, Vizuete, & Mendlewicz, 2001; Hornung et al., 2008; Philipsen et al., 2005). Other discrepancies between findings from PSG studies of BPD and sleep are frequent (Fleischer, Schafer, Coogan, Hasler, & Thome, 2012). Nevertheless, it is interesting that some PSG findings are congruent with results obtained using self-report measures, indicating that there is converging evidence of a relationship between borderline pathology and sleep problems in younger adults. Although studies have investigated borderline personality pathology and sleep problems, very few studies have addressed the relationship between other types of personality disorder (PD) and sleep problems. Sleep problems have been associated with the Five-Factor Model domain of neuroticism (e.g. van de Laar, Verbeek, Pevernagie, Aldenkamp, & Overeem, 2010; Williams & Moroz, 2009) and more specifically with other personality traits that are associated with various PDs. For example, one recent study found sleep problems to be correlated with harm avoidance (Park, An, Jang, & Chung, 2012); high levels of harm avoidance (caution, fear, pessimism, and shyness) are characteristic of avoidant and dependent PDs. Sleep deprivation has been associated with increased superstitious thinking (Kilgore et al., 2008), which is one diagnostic criterion for schizotypal PD. Anxious concerns and traits related to perfectionism have been associated with sleep problems (van de Laar et al., 2010) and are a criterion for obsessive–compulsive PD. Excessive worry related to high levels of anxious concerns and traits related to perfectionism may cause sleep problems (Takano, Iijima, & Tanno, 2012). Additionally, antisocial PD has been associated with increased slow wave sleep (Lindberg et al., 2003; Lindberg et al., 2009) and self-reported sleep problems (Harty et al., 2010; Semiz et al., 2008), although the reported relationships are relatively weak compared to the relationship between BPD and sleep problems. To our knowledge, this is the extent of the literature regarding the other PDs and sleep problems. The literature reviewed earlier suggests that out of all of the DSM-IV PDs, borderline personality pathology, in particular, is associated with significant sleep problems. However, most of the research on this topic has been conducted with young adults, primarily in clinical samples. A gap in the literature exists with respect to the connection between borderline pathology and sleep problems in older populations and in large community samples. At the St Louis Personality and Ageing Network (SPAN), we recruited a representative community sample of 1630 adults who were between the ages of 55 and 64 years to participate in a longitudinal study of personality and health in later life. Previous articles from our study have demonstrated that symptoms of BPD persist into later middle age and continue to have a detrimental impact on several aspects of our participants’ lives, even though few of our participants exceed the DSM-IV threshold for a diagnosis of BPD. For example, symptoms of BPD are associated with increased frequency of threatening life events (Gleason, Powers, & Oltmanns, 2012) and increased likelihood of obesity and various health-related problems (Powers & Oltmanns, 2013). In this paper, we extend our consideration of these difficulties associated with borderline personality pathology to sleep problems. On the basis of the reviewed literature and the nature of affective dysregulation in BPD, it was expected that BPD symptoms would be significantly associated with sleep problems in our sample of older adults, even after controlling for relevant psychological, physical and demographic variables.