What is the Cost of BPD to Society?

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January 11th, 2009 Leave a comment Go to comments

(Click here for more coverage of Borderline Personality Disorder.)

I’d like to encourage people who are aware of Borderline Personality Disorder (BPD) to start spreading the news about how devastating this illness is not just for those who have it and their family members, but for the entire United States economy.

I wrote this post to explain to people who may not have the ability to understand how horrific BPD is from personal experience dealing with an afflicted person. Such people can still likely understand the economic impact of this illness and how it would be far more cost-effective for US mental health care policies to be overhauled to raise awareness and get most of the victims into treatment. The increased government spending appears that it would be entirely offset by savings in government expenses (in such areas of courts and law enforcement) and increases in tax revenues due to a significant improvement in worsened productivity harming families affected by BPD.

Borderline Personality Disorder (BPD) is a devastating but very common mental illness that until recently has been believed based upon DSM-IV (Diagnostics and Statistic Manual of Mental Disorders, 4th edition — a widely used reference book in the mental health field) to affect about 2% of the US population or about 6 million people in the US. Common belief is that it afflicts women about 3 times more often than men.

Recent research published in April 2008 suggests that 6% of the population may be affected and the difference between rates for males and females may be little. If this research is accurate, the United States with its population of about 300 million people has 18 million victims of BPD.

The result of BPD is a catastrophic cycle of child abuse and mental illness that runs for generations. The economic impact of this illness is worse than a 9/11/2001 terror attack each and every year. US mental health care policies are badly in need of an overhaul to deal with BPD and similar personality disorders and the drastic economic impact they have on any tens of millions of US citizens.

People who suffer from BPD may not appear to be complete failures or crazy. In fact they could be very successful and well known. Famous people who are believed to have suffered from BPD include:

Princess Diana
Marilyn Monroe
Joan Crawford
Mary Todd Lincoln (Abraham Lincoln’s wife)
Betty Broderick
Susan Smith

Although the last two people on this list probably are better described as infamous murderers than famous personalities, it’s clear that any notion that all people with BPD are obviously crazed and incapable is not accurate.

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Origins of BPD

Dr. Christine Lawson has described a number of these suspected BPD cases in her book Understanding the Borderline Mother: Helping Her Children Transcend the Intense, Unpredictable, and Volatile Relationship. She has developed a model to explain variations of Borderline behaviors in which they can be classified as hermits, waifs, queens, and witches. The model well captures the variations in behaviors. A particular Borderline may exhibit both a dominant set of behaviors (for instance, a queen who expects admiration, subservience, and loyalty) and an extreme set of behaviors (a witch who will berate, threaten, and even physically harm others) depending upon the circumstances of the moment.

Many Borderlines survived horrific childhoods full of abuse and neglect by one or both parents. BPD is an adaptation for them that probably increased their chances of survival. By developing BPD, they gained tools they could use to anticipate abuse and avoid it by manipulating, distorting, distracting, and blame-shifting onto others. In some sense, their “choice” was to develop BPD and hope to avoid more abuse and trauma or die.

There are some cases of BPD that were not caused by abuse as there seems to be a genetic component. But with most cases, it appears to be learned or conditioned behavior. Borderlines learn destructive parenting skills from their abuse or develop their own destructive behaviors trying to control other people. They often pass BPD to their children because they learned from their parent(s) how to be abusive and that child abuse is among the accepted means of raising children. They therefore often “infect” their offspring with BPD or other mental illnesses, setting their own children up to continue the cycle of child abuse.

While BPD isn’t technically a contagious disease as there is no actual pathogen, I liken BPD to a contagious infection because the Borderline personality itself tends to influence others to develop serious mental health problems. BPD causes mental harm that spreads widely and can cause other people who come into contact with the Borderline to develop symptoms of depression, post-traumatic stress disorder (PTSD), generalized anxiety disorder, substance abuse, and even BPD itself.

Some go on to develop full-blown BPD themselves as they suffer from the abuse inflicted by the Borderline in their lives. This is particularly likely to happen to children as they seldom are emotionally and intellectually developed enough to realize there is something very wrong with the Borderline and unfortunately may believe they deserve the abuse or that it is a normal childhood experience. Adult victims of a Borderline often develop what many call “non-BPD” behaviors which may appear to the naive as being very similar to BPD behaviors, so much so that they may suspect somebody a victim of a Borderline aggressor has BPD because of their reactions and behaviors. But if you take these people out of the environment infected by the Borderline, they revert to more normal behaviors. This is unlike most actual Borderlines who are so ingrained with their maladaptive behaviors that they will apply them in nearly any situation in which they feel some discomfort or unease, particularly when it involves people emotionally close to them.

Borderline Behaviors

Borderlines are “master manipulators” in many cases. They are emotionally intense. Many, probably most, lie pathologically. Most people are fooled by their lies as they lie about things small and large so often that they get very good at it. They often have chaotic and unpredictable emotions, and when upset can fly into violent rages. The triggers for these rages may not even be things that a normal person would find upsetting — they may even be compliments from another person.

Some Borderlines engage in cutting, burning, or other self-mutilation attempts. About 10% die by suicide, usually after many suicide attempts that land them in hospitals due to drug overdoses, wrist cutting, and other self-inflicted injuries.

Borderlines tend to have problems with anger and respecting the boundaries of other people. Their rages can be very intense and deeply disturbing to the people around them. They may start for no apparent reason, go on for extended periods of time, and then stop for no apparent reason. Often, they show their rages and out of control emotions primarily or only to people very close to them. Their co-workers and acquaintances may have no idea how the person acts when with family members and have difficulty believing how verbally, emotionally, psychologically, and sometimes even physically abusive they can be.

Borderlines often use the influence they have to destroy their enemies without mercy and without any semblance of ethics. BPD is driven by the instinct to survive and a very strong fear of abandonment that causes the victims to harm others to try to control them.

The break-up of relationships, divorces, and child custody battles are prime cases of situations in which Borderlines will engage in even worse abuse than usual. Each of these situations is very stressful for anybody. But for a Borderline, these circumstances are often irresistable motivators for one who typically engages in secretive emotional and verbal abuse to resort to a very public attack campaign involving false abuse allegations and defamation against the ex. Some Borderlines will even go so far as to frame the ex for child abuse by physically abusing a child and setting it up to make like the ex did the crime. Young children, particularly babies and toddlers, are the most likely to be abused like this as older children can usually explain what happened and might make it clear to others that the Borderline parent is the actual abuser.

Impact on Society

Awareness of BPD is more important to the long-term well-being of Americans than the war on terror. While terrorists manage to kill a few thousand people in the US each decade or so, Borderlines cause far more damage and that damage directly and severely affects far higher numbers of people. Based upon the DSM-IV statistics on the illness at 2% of the population, there are 6 million Borderlines in the US. Estimates are that 30 million US citizens are adversely affected on a daily basis by those suffering from BPD. As mentioned, recent research suggests the numbers may be 3 times higher if the 6% rate is accurate. If even half of these people could be treated and helped to significantly control their destructive behaviors, the reduction in child abuse, senseless litigation, engagement of police and CPS resources in witch-hunts against those falsely accused by Borderlines, unnecessary medical resources used for treating Borderline self-mutilation and suicide attempts, and the passing of all of these problems on to the next generation would be of more economic benefit than preventing another 9/11 level terrorist attack.

With 10% of Borderlines dying by suicide and a suicide death peak for Borderlines in the mid-30s, the number of deaths from BPD suicides alone each year is probably far larger than 3000 or so deaths from the 9/11/2001 Al Qaeda attacks. This doesn’t include the damage to the victims of the Borderlines, generally their families and close friends.

According to NIMH estimates, in 2004 suicides were the 11th leading cause of deaths in the US with 32,439 deaths by suicide, with between 8 and 25 suicide attempts per death. The overall suicide rate for the US popultion is about 1/100 of a percent.

The suicide rate for Borderlines is far higher, but can be reduced via treatment. A recent study showed that Dialectical Behavior Therapy cuts the Borderline suicide rate by about half. However, getting Borderlines into treatment in the first place is very difficult. They tend to believe there is nothing wrong with themselves and avoid treatment or drop out of it.

The Borderline suicide rate is about 25 to 50 times that of the general population. This is based upon the finding of 8.5% of Borderlines in 16-year study died by suicide. (See Clinical Aspects of Borderline Personality Disorder – Section 2) If projections using these statistics were to hold true, that could mean approaching half the suicides in the US each year are by people suffering from BPD, equivalent to 5 to 10 times the number of deaths from the 9/11 terror attack per year.

Further, consider that it is not just Borderlines dying. Their victims often die, too. People targeted by BPD distortion campaigns may quickly find themselves marginalized out of their lives, treated like lepers, and sometimes arrested, prosecuted, and even imprisoned on false allegations made by malicious Borderlines out to create great harm in pursuit of their agenda of abuse as a means of self-defense. Such victims learn there is no hope for the future because society refuses to deal with the Borderline abuser and instead blames them, the actual victims, for everything. Some of these people end up taking their own lives, either intentionally perhaps due to extreme depression or because they develop their own set of maladaptive behaviors such as substance abuse that lead to their early demise.

Estimating the Harm from BPD in Economic Terms

How do you estimate the negative economic impact BPD causes? The range in behaviors of those believed to have BPD goes anywhere from annoying to homicidal, literally murdering others as Betty Broderick and Susan Smith did. Although homicide is on the extreme end of behaviors, typical Borderline behaviors are still very destructive. They include child abuse, spousal abuse, false accusations and harassment, and self-mutilation and suicide attempts. Frequently police, CPS, the courts, mental health care providers, and medical providers are engaged in providing a much higher level of services to the BP and those affected by the BP’s attacks and harassment. There is also an economic impact by lost productivity due to the emotional and psychological destruction inflicted by the Borderlines on themselves and on others.

Regarding the increased level of services consumed by these people and those they abuse, let’s estimate that in the typical years, a typical BP causes 1 day of litigation, 1 day of police activity, 1 day of CPS activity, and 1 day of wasted medical resources. All of that is compounded further by passing the problems on to the next generation as research shows that BPs pass mental illness on to their children, anything from anxiety to BPD to becoming serial killers like Edmund Kemper. Those estimates for the economic time impacts of BPs are far below that of Borderlines engaged extensively in the family law and legal systems, but may be above those who do not have active family and relationship conflicts.

Figure the fully burdened cost of each of these days is based upon a typical big-city legal fee hour of $250. Police and CPS agents don’t cost that much for the front-line folks, but they have cars, guns, administrators, etc. — the real costs mount quickly. And on the legal front, you have two or three lawyers (there is often a GAL [Guardian Ad Litem] or minors’ counsel involved in many hearings because eventually the BPs destructiveness starts to be noticed and the courts realize, perhaps years too late, that they should have been doing more to protect the children), judge, court clerks, bailiff, reporter, etc. to count. Estimate at 4 days times 8 hours times $250 per hour and you get $8000 per year, per BP.

$8000 per year may be conservative by far during periods of high-conflict divorces and child custody battles involving Borderlines, whether they have been diagnosed with BPD or have not but exhibit the behaviors. One example is a divorce and child custody case that has had a financial impact on the order of $600,000+ in adverse economic impact incurred over the initial few years as destructive behaviors exploded out of control with no end in sight. The rate of wasted financial resources in such cases often remains very high for years, often until all the children become 18 years old or even longer. Such financial damage includes unnecessary legal costs often due to frivolous litigation, lost wages, lost jobs, waste of law enforcement and judicial resources, and the damages caused by abuses committed by law enforcement and courts that create more harm as they are slow to understand the Borderline is a vindictive and manipulative liar while in the meantime they severely harm other parties and the children. Such cases do not appear unusual given the many writings of people who have similarly suffered at the hands of a person afflicted with BPD. To get an idea of the magnitude of damage in such a case spread over a lifetime, divide $1 million by 50 years of adult lifetime and the result is $20,000 per year.

Borderlines often manage to not completely fall apart and start destroying those around them until they have managed to have a child or more than one, and even then still hide it from nearly everybody except their families and the many government, legal, and medical people who wrongly think the non-BP spouse or girlfriend/boyfriend is an abuser or has other problems. Sure enough they do have problems, but when BPs are involved, it is more like those being accused of abuse are in fact victims of abuse who don’t even understand they are being abused. Yet they are accused of all that is going wrong because the Borderlines are usually amazingly good liars and manipulators.

Let’s assume that $8000 to $20,000 is a rough range of annual costs. Add up the $8000 and $20,000 estimates and divide by 2 for an average. The result is $14,000 as a typical annual cost per year per BPD victim. This seems a rational estimate for something that is not easy to estimate. But to be extra-conservative, let’s round down to $10,000 per year for the average negative financial impact from a Borderline.

If you accept the DSM-IV estimates of 6 million Borderlines in the US, then multiply $10,000 per year by 6 million and you get $60 billion. If you believe it may be closer to recent studies around 6% of the population, 3 times higher than DSM-IV estimates, then the figure is $180 billion. That’s per year. Then compound by passing this on to the next generation, and by having these problems happen year after year as hardly any of these people are getting treatment and few of them are learning to control their destructive behaviors or getting well.

We haven’t yet figured in estimates of the lost productivity impact. Having most or all of your friends and/or coworkers start to hate you because you’ve been systematically vilified by a Borderline, being investigated by the police and CPS due to unrelenting false allegations, having your children taken away, being kicked out of your home, consequent depression, anxiety, and other mental illlnesses is common for those with relationships with BPs. That has an economic impact, if for no other reason that increased healthcare spendings and lost productivity. These things happen to the significant others of BPs every day. And remember there are many people closely connected to each BP who suffer like this. Surviving a Borderline Parent cites an estimate of 30 million people are affected daily by Borderlines. This is based upon the DSM-IV rate of 2% of the population suffering from BPD. That means about 5 people impacted by 1 BP which seems pretty conservative again as some (husbands, wives, parents, children — even adult children of BPs often suffer for their whole lives) are far more impacted than nearly all others. Figure 10 mental health and doctor’s appointments at $125 each, $500 of medicine, 2 days of lost productivity at $125 per hour and you get a wild but reasoned guess of maybe $3750 per year. Times 5 given the 5 to 1 ratio from Surviving a Borderline Parent, then times 6 million BPs. So that’s $112.5 billion in impact to the non-BPs who are suffering because the BPs are behaving poorly because nobody can help them or they deny they need help.

Using the lower DSM-IV rate of 2%, add $60 billion plus $112.5 billion and you get $172.5 billion. That’s about 5.6% of the US federal budget of $3.1 trillion for 2009. If the higher rate of 6% is accurate, then it is $517.5 billion or about 16.7% of the US federal budget for 2009. Although they may be hard to quantify, if the economic impact of BPD is anywhere in the neighborhood of these numbers, it is huge.

As to the economic impact of 9/11, that one-time event according to the paper “The Economic Impact of September 11th” looks to have had an impact in $50 billion to $100 billion range, plus questionable spending on the war on terror and other “projects” of another $100 billion. So that’s the $150 to $200 billion range, but much of it is one-time and much of it is questionable whether it is even necessary.

Comparing 9/11 with BPD is like comparing the economic impact of your home being demolished by a tornado once per 100 years versus it being washed away in floods once every 2 years. The tornado (9/11) might be more frightening and kill more people, but the floods (BPD) do more damage yet don’t seem to frightening because they are so regular and predictable because you built and rebuilt your home on a riverbank.

Perhaps now you can see why it looks like the economic impact of BPD may very well be a much bigger problem than 9/11 and the war on terror have been. The economic impact is hidden as it doesn’t involve huge explosions and big military budget appropriations. But that doesn’t make it any less real.

Reducing the Harm from BPD Requires Societal Changes

Borderline Personality Disorder warrants a massive awareness campaign and significant changes to US mental health care policies to get the victims into treatment. The financial damage from this disease is staggering. The cost of treating it is likely far less. But getting these people treated will require changes in the law to require personality disorder victims, in particular BPD victims, to receive treatment and funding to pay for it.

Typical treatment consists of a psychotherapy session per week plus common psychiatric medications. Estimate 50 therapy sessions per patient at $80 per session plus $1000 on psychiatric drugs and dietary supplements per year and that is $5000 per patient per year. Times 6 million patients (per the DSM-IV estimates) and that nets out to $30 billion per year. That’s only about 1/6 of the cost of negative economic impact from this illness. Even if only half of the negative economic impact could be prevented by this level of therapy and medication, that’s still a savings in excess of $50 billion per year in the US alone.

If the newer prevalence rate of 6% is right, the savings could be 3 times that much — $150 billion per year.

Furthermore, funding for research into diagnosing and treating BPD should be expanded. If it is possible to significantly reduce the cost of diagnosing and treating its victims, the potential additional savings enabled by this research could be huge. For instance, if $10 billion in research over a decade could cut the DSM-IV related estimate of $30 billion per year in treatment costs to even $25 billion per year, it would pay for itself quickly.

Then there is the moral and ethical argument for helping Borderlines. For one, almost all of them are victims of extreme child abuse themselves. Then they victimize others and spread the damage far and wide. It’s simply wrong for society to permit this to happen, but the reality today is that the government and courts often enable, encourage, and assist Borderlines at abusing their victims.

angiEmedia