Borderline Intellectual Functioning: A Masquerader in Patients with Confusing Psychopathology

¹Senior Resident, Department of Psychiatry, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India

²Junior Resident, Department of Psychiatry, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India

³Assistant Professor, Department of Psychiatry, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India

*Corresponding Author: Sumeesha Jaswal, Senior Resident, Department of Psychiatry, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India, Phone: 09459541400, Email: [email protected]

Received Date: April 07, 2025

Published Date: May 15, 2025

Citation: Jaswal S, et al. (2025). Borderline Intellectual Functioning: A Masquerader in Patients with Confusing Psychopathology. Mathews J Psychiatry Ment Health. 10(1):51.

Copyrights: Jaswal S, et al. (2025).

ABSTRACT

Borderline intellectual functioning is recognised as a condition which requires early intervention but is not given as an independent diagnosis in any diagnostic manual. This is despite the multitude of dysfunction faced by the patient as well as caregivers of patients. Those with borderline intellectual functioning are particularly at high risk of psychiatric illnesses. We present the case of our patient presenting in our practice with assessment of their psychopathology being colored by the presence of borderline intellectual functioning. The final diagnosis for the patient was Obsessive compulsive symptoms with Anxious personality disorder (F60.6) and Intentional self-harm by hanging, strangulation and suffocation(X70) with Borderline intellectual functioning. He improved on pharmacological and behavioural interventions. This shows that BIF is incapacitating and a person likely has problems in daily functioning. Our case reports highlight the unmet needs of a person having borderline intellectual functioning.

Keywords: Borderline Intellectual Functioning, Obsessive Compulsive Symptoms, Anxious Personality Disorder, Diagnostic Masking, Diagnostic Overshadowing.

INTRODUCTION

Borderline intellectual functioning has been relegated in the current diagnostic manuals to a descriptive V code in DSM 5 while ICD 10 had previously mentioned it under code R48.83 [1,2]. ICD 11 while recognises it as a condition which requires early intervention but does not value it as an independent diagnosis despite the multitude of dysfunction faced by the patient as well as caregivers of patients with borderline intellectual functioning [3].

In DSM-IV-TR, BIF was defined by an IQ range that is at least one standard deviation (SD) below the population mean [4]. Full-scale intelligence quotient (IQ) is now being considered an outmoded concept and is decreasingly being used but it helps in labelling people with borderline intellectual functioning (BIF) have intelligence quotient (IQ) scores and other indices of cognitive functioning that are significantly low, but not so low as to cause them to be labeled with disorders of intellectual development [5]. Current diagnostic systems lack any definition for this category.

Hassiotis et al. (2008) in their study reported that 12.3% of the sample collected UK Wide Cross-Sectional Survey of 8450 adults living in private households had borderline intellectual functioning, and compared to their peers with average intelligence, this group had increased rates of neurotic disorders, depressive episodes, phobias, substance misuse and personality disorders, but not psychotic disorders. Further, this group was more likely to receive psychiatric medications and to utilize more community and daycare services [6]. Thus, this population is particularly at high risk of psychiatric illnesses.

Diagnosis in those with BIF is also affected by diagnostic masking and overshadowing which leads to difficulty in diagnosing psychiatric illnesses in this population [7].

We present the case of our patient presenting in our practice with assessment of their psychopathology being colored by the presence of borderline intellectual functioning.

CASE

A 41 years old male, educated up to 10^th std., working as a mechanic , belonging to Hindu Nuclear Family of Lower Socioeconomic status of rural background with poor educational background of family of origin presented to us with an illness of 17 years though exact duration and onset was not known due to lack of informants, with illness characterized by oddities in behaviour like at times bathing with detergent or brushing teeth with same, sexually inappropriate behaviour, worries, excessive somatic concerns, repetitive checking behaviour with excessive reassurance seeking, impulsive suicide attempt of low intentionality and low lethality due to poor stress tolerance after being made fun of by his children. He was noted to have low self-esteem, poor understanding, low frustration tolerance, irritability, worries regarding social perception, job absenteeism due to fear of criticism and disapproval, negative self-image with belief that he was inferior to others, inability to fulfil expected social role and responsibility (being unable to take care of his children), poor consequential thinking and risk recognition, poor future planning,  difficulty in practical skills of money management and using newer appliances, doubts regarding fidelity of his wife fearing that she would leave him for someone better, with history of use of alcohol, cannabis and tobacco in a dependent pattern and occasional use of opioids. Mental status examination showed anxious affect; speech seemed irrelevant at times. Cognitive function test showed – attention aroused but not sustained, poor immediate memory, poor intelligence, concrete thinking, poor judgement and absent insight. A diagnosis of Borderline intellectual functioning with obsessive compulsive symptoms with Anxious personality disorder (F60.6) and Mental and behavioural disorders due to use of cannabinoids, dependence syndrome (F12.2), Mental and behavioural disturbances due to use of tobacco, dependence syndrome (F17.2) and Intentional self-harm by hanging, strangulation and suffocation (X70) was kept. IQ testing showed IQ score of 68. Patient improved on tablet fluoxetine given up to 60 mg along with 2 mg risperidone, and naltrexone 50 mg for substance use disorder along with behavioural intervention in the form of goal specification, task analysis and rewarding good behaviour. Patient’s employer and partner were psycho educated regarding illness and behavioural management. This resulted in improvement in terms of no job absenteeism, no reassurance seeking or odd behaviours.

DISCUSSION

People labelled with Borderline intellectual functioning (BIF) typically score lower on tests of intellectual ability and other indices of cognitive functioning than the general population, but not to the extent to be defined as an intellectual disability. BIF does not present with a specific symptom or set of symptoms but as a continuum of risk across the lifespan. The closer the proximity to Intellectual Disability, or greater the degree of cognitive and adaptive impairments, the higher the likelihood of associated risks that need to be monitored throughout development in order to encourage better coping strategies and healthy behaviours [8].

Emerson et al. in their findings reported that children with BIF had an increased risk of mental health problems [9]. Mental health problems in people with borderline intellectual functioning may not be well addressed in general psychiatry, or by standard psychiatry for patients with ID [10].

BIF often goes unrecognised by health or social care professionals, who do not receive routine training in the identification of BIF or in adapting interventions to address their cognitive needs, resulting in inappropriate or lack of formal support. The lack of attention given to BIF persists not only through professional services but through research, with comparatively little interest in investigating this group [8].

Individuals with borderline intellectual functioning were 2.37 times more likely to have a psychiatric diagnosis (95% CI=2.30–2.45) and 1.2 times more likely to use drugs (95% CI=1.07–0.35) than those with average IQ. These results suggest that adolescents with borderline intellectual functioning are more likely to suffer from psychiatric disorders, poor social functioning and drug abuse than those with average intelligence, and that borderline intellectual functioning is a marker of vulnerability to these poor outcomes.

Some studies indicate that low IQ is associated with risky health behaviors, such as alcohol abuse, and cigarette smoking [11].

Our patient suffered socially at his workplace and at home due to his BIF which was resultant in poor self-image. His psychopathology was understandable more in line with BIF. The findings have also been supported in literature.

CONCLUSION

Borderline intellectual functioning requires early intervention to prevent development of psychopathology. This shows that BIF is incapacitating and a person likely has problems in daily functioning. Our case reports highlight the unmet needs of a person having borderline intellectual functioning.

ACKNOWLEDGEMENTS

None.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

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